LIBRARY OF CONGRESS, 



©|ap. Onjujrigljt "tya 

Shelf 

yNITED vSTATES OF AMERICA. 



ANALYSIS OF THE URINE, 

WITH SPECIAL REFERENCE TO THE 

DISEASES OF THE GENITO-URINARY 
ORGANS. 



K: B. 



B^ 



HOFMAKN, 



PROFESSOR IN THE UNIVERSITY OF GRATZ, 



AND 

R; .ULTZMANN, 

DOCENT IN /THE UNIVERSITY OF VIENNA. 



., 



TRANSLATED AND EDITED BY 

T. BARTON BRUNE, A. M., M. D., 

FORMERLY PROFESSOR OF THE PRACTICE OF MEDICINE IN THE BALTIMORE POLYCLINIC AND 

POST-GRADUATE MEDICAL SCHOOL, AND LECTURER ON CLINICAL MEDICINE 

IN THE UNIVERSITY OF MARYLAND, 




4- 



V 



H. HOLBROOK CURTIS, Ph. B., M. D., 



FELLOW OF THE NEW YORK ACADEMY OF MEDICINE, MEMBER OF THE COUNTY SOCIETY, ETC. 



THIRD EDITION, REVISED AND ENLARGED. 



NEW YORK: 
D. APPLETON AND COMPANY. 

1, 3, and 5 BOND STREET. 
1889. 



& 

i ^ 



«« 



Copyright, 1879, 1886, 1889, 
By D. APPLETON AND COMPANY. 






TEATsrSLATOES' PEEFACE. 



We have undertaken the translation of this little 
work, hoping that it will supply a need which has 
been long felt by American students and physicians. 
We do not know of a single work in the English 
language where, in a concise form, so many valuable 
suggestions and practical hints are offered, both as 
regards analysis and diagnosis. The book does not 
pretend to be an elaborate and exhaustive treatise on 
the diseases of the genito-urinary organs; such an 
idea is at once precluded by the title and size of 
the work. It merely claims to contain all that is 
necessary for the student and practicing physician. 

The merit of the work is sufficiently attested by 
the popularity it already enjoys in Germany and Aus- 
tria, and the fact of its having appeared in three 
languages during the year of its publication. 



4 TRANSLATORS' PREFACE. 

While making no claims to elegance of translation, 
we have endeavored to be faithful to the original text, 
and at the same time to explain the methods of pro- 
cedure so clearly, that without other aids the student 
may be able to perfect himself in the rapid analysis 
of the uiine, and furthermore to draw his conclusions 
from the same. The added plates, which do not appear 
in the German edition, are principally taken from 
"Ultzmann and Hofmann's Atlas der physiologischen 
und pathologischen Harnsedimente," and from photo- 
graphs kindly furnished by Dr. Ultzmann, under whose 
supervision we have performed our work. 

The Teanslatoes. 

Vienna, December 20, 1878. 



AUTHOES' PEEFACE. 



De. T. Baeton Beune, A. M., M. D., and De. H. 

Holbeook Cttetis, Ph. B., M. D., the translators of 
our " Analysis of the Urine," have requested of us a 
preface for the Second English Edition. 

We willingly comply with this request, and wish 
to express our gratification at the reception our book 
has met with in the United States. Our object in 
writing has been to provide practitioners in medicine 
with a clear and concise guide to the diagnosis of dis- 
eases, especially those affecting the urinary apparatus. 

We have eliminated all unnecessary matter, and 
have endeavored to make our processes so simple that 
but a limited knowledge of chemistry will be necessary 
to understand our tests. Though we could not our- 
selves undertake to revise the new edition, on account 
of the distance and the limited time allowed for the 



6 AUTHORS' PREFACE. 

introduction of new matter, we do not doubt that the 
high qualifications of the translators will be a warrant 
for the correctness of the work. 

Prof. K. B. Hofmann. 
Dr. R. Ultzmann. 

Vienna, Austbia, February, 1886. 



TEA^LA'TOES' PEEFAOE TO THE 
SECOND EDITIOK 



The raison d'etre of this edition is to be found in 
the recent advances made in urinary analysis, particu- 
larly during the last three years, and in the gratifying 
fact that, in spite of the simultaneous appearance of a 
translation made in the West and unauthorized by the 
authors, our own translation has been exhausted. We 
have endeavored to revise the previous edition, and to 
incorporate in this all that has recently been added 
to our knowledge which will be of especial interest to 
the student and practitioner of medicine. At the end 
of the work is appended a translation of Dr. TJltz- 
mann's description of his saccharimeter. All addi- 
tions made by us to the original text are inclosed in 

brackets [ ]. 

The Translators. 

December 15, 1885. 



TRANSLATORS' PEEFACE TO THE 
THIRD EDITION. 



It is a fact pleasing to the translators and editors 
of this work that a third edition should be called for 
in so short a time after the appearance of the second. 
And yet, short as the time has been, so much has been 
published during this period upon the investigation of 
the urine that it has been no easy task to incorporate 
in the present volume all the recently acquired knowl- 
edge which is of importance for physicians and stu- 
dents of medicine. Much has necessarily been omitted, 
but we do not believe that it has been to the detriment 
of that portion of the public for whom this work is 
intended. 

In the form of appendices we have introduced a 
short sketch of albuminuria in its latest aspects, and 
have mentioned some of the newer and more promising 
tests for albumen and sugar. We have also given a 
brief account of some reducing substances which are of 
practical importance in view of their reactions with 
certain tests commonly used for the detection of sugar. 

As before, our additions to the text are inclosed in 
brackets [ ]. 

The Translators. 



TABLE OF CONTENTS. 





PAGE 


Introduction ....... 


. 13 


CHAPTER I. 




Histology of the Urinary Organs 


19 


1. The Kidneys ....... 


. 19 


Urinary Tubules ..... 


21 


Blood-vessels of the Kidneys .... 


. 24 


Nerves of the Kidney ..... 


26 


2. The Excretory Ducts . . . . . 


. 26 


Ureters, Kidney-pelvis, and Calices . 


26 


Urinary Bladder ...... 


. 27 


Male Urethra ...... 


28 


Female Urethra ...... 


. 29 


CHAPTER II. 





The Excretion of the Urine 



CHAPTER III. 



The Urine .... 

A. A General Description . 

B. Physical Characteristics 

1. Amount 

2. Specific Gravity 

3. Solid Ingredients . 

4. Consistence 

5. Color 

6. Transparency and Fluorescence 

7. Odor 

8. Reaction 

C. Chemical Composition . 

a. Normal Organic Constituents 

1. Urea . 

2. Uric Acid 

3. Coloring Matters 



35 
35 
36 

3G 
37 
3S 
41 
42 
45 
46 
46 
4-' 
4s 
49 
56 
63 



10 



TABU 



D 





PAGE 


a. Urobiline ...... 


. 64 


&. Urine-Indican ...... 


66 


4. Other Normal Organic Constituents . 


. n 


. N rraal Inorganic Constituents .... 


73 


1. Chlorides 


. rs 


2. Phosphates ....... 


76 


a. Earthy Phosphates .... 


. 77 


0. Alkali Phosphates .... 


80 


3. Sulph:. s ...... 


. 82 


c. Abnormal Constituents ..... 




1. Albumen . . . . . . 


84 


Xitric Acid Test ..... 


- 


Boiling Test ...... 


. 89 


[a.] Peptone ..... 


95 


Potasseo-mercuric Iodide Test, for 


. 99 


Picric Acid Test, for .... 


100 


Sodium. Tungstate Test, for 


. 102 


Potassium Ferrocyanide Test, for 


102 


Metaphosphoric Acid Test, for . 


. 102 


• igar ...... 


104 


Heller's Test 


. 105 


Mulder's Test ..... 


107 


Oliver's Test Papers ..... 


. 107 


Trommer's Test ...... 


107 


Robert's Test ...... 


. 109 


Bottger's Test ..... 


110 


Picric Acid Test ..... 


. 112 


I's Method of Approximative Determination 


118 


Inosite ...... 


. 120 


3. Leucine and Tyrosine .... 


124 


4 Abnormal Coloring Matters .... 


. 125 


a. Uroerythrine ..... 


125 


/3. Vegetable Coloring Matters 


. 127 


7. Blood Coloring Matters 


128 


8. Biliary Coloring Matters .... 


. 131 


5. The Bile Acids .... 


136 


6. Carbonate of Ammonium 


. 140 


9 .Iphuretted Hydrogen .... 


143 


8. Accidental Constituents .... 


. 143 


Tie Sediment ....... 


146 


Urine Fermentation ...... 


. 146 


Classification of the Sediment .... 


150 


a. The Unorganized Sediment .... 


. 151 


1. Urate- ...... 


151 


2. Urate of Ammonium .... 


. 153 


3. Uric Acid 


154 


4 Calcium Oxalate . . , 


. 155 



TABLE OF CONTENTS. 



11 



5. Cystine 


. 


156 


6. Leucine and Tyrosine 




. 158 


7. Fat 


. 


159 


8. Earthy Phosphates 


. 


. 161 


9. Magnesium Phosphates 


. 


164 


10. Triple Phosphates . 


. 


. 164 


11. Calcium Carbonate 


. 


165 


b. The Organized Sediment 


. 


. 165 


1. Mucus . 


. 


165 


2. Epithelium 


. 


. 167 


3. Pus-corpuscles (Donne's 


Test) 


169 


4. Blood-corpuscles . 


. 


. 171 


5. Cylinders 


. 


173 


6. Fungi 


. 


. 179 


7. Spermatozoa . 


. 


183 


8. Cancer Elements . 


. > 


. 184 


9. Entozoa 


. 


186 


Addenda. 




CRETIONS .... 


• • • 


. 189 


Analysis of the Concretions . 


• • < 


192 



CHAPTER IV. 

Reagents and Apparatus for the Approximative Determination of 

the Urine Constituents ...... 197 

Reagents ......... 197 

Apparatus ......... 198 

CHAPTER V. 



Quantitative Determination of a few of the Constituents of 
Urine ...... 

I. Estimation of the Degree of Acidity . 
Estimation of the Solid Matters . 
Estimation of Urea .... 

1. Liebig's Method 

2. Bunsen's Method 

3. Knop-Hiifner's Method * . 
Determination of Uric Acid . 
Determination of Creatinine 
Determination of the Total Amount of Nitrogen 
Determination of Albumen 
Determination of Sugar 

1. Fehling's Method . 

2. Knapp's Method 



II. 

III. 



rv. 

v. 

VI. 

VII. 

VIII. 



200 
201 
201 
202 
202 
208 
209 
210 
212 
213 
215 
216 
216 
218 



12 



TABLE OF CONTENTS. 



IX. Determination of Chlorine 
X. Determination of Phosphoric Acid . 
XI. Determination of Sulphuric Acid 

CHAPTER VI. 

Key to the Approximative Analysis of the Urine 
Chemical Investigation 

A. Nitric Acid .... 

B. Heat Test 

C. Test for the Normal Coloring Matters of the Urine 

D. Test for the Normal Inorganic Salts of the Urine 

E. Further Tests for Abnormal Matters 

F. Investigation of the Sediment . 



PAGK 

219 
221 
223 



224 
224 
224 
225 

227 
227 
227 
227 



CHAPTER VII. 



General Diagnosis 



232 



or Des 



CHAPTER VIII. 

Diagnosis of the Diseases of the Urinary Apparatus 

A. True Albuminuria 

1. Hyperemia of the Kidney 

2. Parenchymatous Nephritis . 

a. Acute Parenchymatous Nephritis . 

a. Catarrh of the Urinary Tubules, 

phritis . 
j8. Acute Parenchymatous Nephritis 

b. Chronic Parenchymatous Nephritis 

3. Interstitial Nephritis 

a. Hyperplastic Interstitial Nephritis — 

ney — Genuine Kidney Atrophy 

b. Suppurative Interstitial Nephritis . 

4. Amyloid Kidney 

B. Forms of Mixed Albuminuria 

1. Pyelitis . . ■ . 

a. Acute Pyelitis 

b. Chronic Pyelitis . 

c. Pyelitis Calculosa . 

d. Pyelitis Tuberculosa 

2. Hematuria 

3. Cysto-Pyelitis and Pyelo-Cystitis 

C. Forms of False Albuminuria . 

1. Cystitis— Bladder-Catarrh 

2. New Growths in the Bladder 

3. Bladder-Stone. 

4. Diseases of the Urethra and Prostate 
Description of Ultzmann's Saccharimeter 

APPENDICES ..... 



proper 



Cirrhosis of the 



quamative 



Ne- 



Kid- 



241 
242 
242 
245 
245 

246 

247 
249 
251 

252 
253 
255 
258 
258 
259 
261 
262 
265 
268 
279 
280 
281 
288 
297 
298 
301 
:J06 



ANALYSIS OF THE URINE, 



INTRODUCTION. 

The results of the generally complicated chemical 
processes upon which depends the basis of animal life 
are, on the one hand, the building up of the body, and 
on the other the breaking down of the same, both 
included in the common term " regressive (?) tissue meta- 
morphosis." The used-up material — i. e., that which 
has lost its value to the animal economy — becomes 
eliminated by the skin and lungs (chiefly in gas form), 
and by the intestines and kidneys (in solid or liquid 
form). 

In order to have a perfect conception at various 
times of the nutrition and state of the body (including 
the normal or pathologically changed material), the 
greatest possible care must be exercised in the investi- 
gation of the excretory ducts themselves, their precise 
function, and the nature of the material eliminated by 
them. 

In order that the physician may obtain an adequate 
idea of the changes which take place in the organs of 



14 INTRODUCTION. 

the body, it is important to observe carefully that most 
inrportant secretion of the same, the urine. 

The urine indicates, at least veiy nearly, by its 
qualitative and quantitative changes, the variation in 
tissue life. It offers in addition the advantage of easy 
collection, and its analysis, so far as it interests the 
practicing physician, can be made with simple appa- 
ratus. The kidney, inasmuch as it is subjected to dis- 
ease, is not a lifeless filtering machine. Through its 
pathological processes material is added to the urine, 
from the presence of which alone is the physician able 
to make a diagnosis. The urine offers also in general 
an indication as to the condition of the entire body 
(including its constitutional diseases), and in particular 
concerning the secretory and excretory urinary appa- 
ratus. On account of the peculiarities of the numerous 
substances excreted by the kidneys, the urine possesses 
a great interest for the physiologist and chemist, and 
under certain circumstances for the medico-legal expert. 

The endeavor to diagnose disease from observation 
of the urine extends back to the remotest period of 
medical research. The changes of the urine did not 
escape Hippocrates in his close investigation of diseases. 
He taught his scholars, under his personal supervis- 
ion, the symptomatic and prognostical signification of 
changes in the urine, so far as the then existing state of 
the other sciences permitted. He directed attention to 
the external characteristics of the urine, its abnormal 
amount, color, and clearness, its cloudy or muddy ap- 
pearance, and the visible differences of the sediment ; 



INTRODUCTION. 15 

and he referred these indications to diseases of the 
urinary organs. However arbitrary his explanations of 
the appearances may be, his observations are for the 
most part correct. He even endeavored to demonstrate 
the influence of various foods and drinks on the consti- 
tution of the urine. We find also in the descriptions of 
diseases by Grecian writers the character of the urine 
considered according to his methods, without departing 
materially from the views of the great Coic physician. 
Since Galen more sharply defined and systematized the 
teachings of Hippocrates, they have prevailed as incon- 
testable truths. For a long time after Hippocrates the 
investigations on the urine made no progress. Through 
the following century one finds but an occasional writer 
who added anything by his own investigations to these 
transmitted treasures. 

To the Arabian Ibn Sina (980-1037), usually known 
as A vicenna, belongs the merit of having called atten- 
tion to the fact that different external circumstances, as 
fasting, wakefulness, over-exertion, and strong emotions, 
have an influence upon the character of the urine. He 
proved also that absorbed medicines which are excreted 
by the kidneys would cause an accidental coloring of 
the urine. By his successors in the Arabian school 
nothing of importance was added, although, particularly 
In the East, each court had an examiner of urine (uro- 
scqperi). The most important writer on this subject in 
the ancient and middle ages is without doubt Johannes, 
surnamed Actuarius, who lived in the thirteenth century 
at the Byzantine Court. Uniting his experiences with 



16 ISTBODUCTJOX. 

the observations of the Hippocratic-Galenic schools, he 
treated in his seven-voluined work " irepl ovpwv" in the 
minutest detail, the physiological and pathological 
changes of the urine. He gives even a description of 
the best methods of observation. In this he excels 
because of his clearly detailed demonstration. This 
work, in which nearly everything was exhausted which 
could be accomplished by the then existing methods, 
found in succeeding time so little emulation that this 
part of aetiology more and more declined. How far the 
interpretation of changes in the urine had advanced is 
most clearly demonstrated by the circumstance that it 
furnished material for the satirical representations of the 
Dutch school of genre painting, as well as for many 
comedies of Moliere and other poets. 

As they had most defective ideas as regards the 
chemical composition of urine, it was possible for the 
old observers to take into consideration only its physical 
properties. We can expect time progress only when 
chemistry and its methods of investigation have under- 
gone marked development. This decided advance dates 
froni the time of Lorenzo Bellini of Florence (1643- 
170-4). Bellini evaporated the urine, and observed that 
by the gradual addition of water the residue was again 
dissolved, and the solution gradually brought back to 
its original condition, through different degrees of color 
and taste. He concluded thereupon that the variation 
of color and taste depended upon the ratio of the con- 
tained water to the solid constituents — a conclusion upon 
which even now Vogel's color scale is based. 



INTRODUCTION. 17 

Now important chemical discoveries followed quickly 
upon one another. Willis discovered sugar in the urine. 
Brandt discovered phosphorus, the origin of which 
MarkgrafF attributed to the contained phosphates. 
Rouelle the younger discovered urea in 1773, and found 
that in the urine of herbivora were contained carbonate 
of calcium and a substance, hippuric acid, related to 
flowers of benzole. In the year 1770 Cotugno found 
albumen in the urine ; in 1798 Cruikshank declared the 
relation of this condition to dropsy ; and in 1827 Bright 
proved the connection between kidney disease and al- 
buminuria. At the same time attention was turned to 
the chemical analysis of gravel and calculi. Among 
the numerous deserving works on this subject are those 
of Scheele, Wollaston, Wetzlar, and Prout. 

The present advanced state of uroscopy is due 
chiefly to the labors of two Frenchmen. Rayer's re- 
searches, which are included in his great work "Les 
maladies des reins" (1837-41), laid the foundation of 
our present knowledge of kidney diseases. Becquerel, 
the son of the renowned physicist, had busied himself 
for a long time with urine analysis under Andral's di- 
rection, to whom he modestly assigns the credit of stim- 
ulating him to his investigations. He published the 
results of years of observation in his work " Semiotique 
des urines" (1841). Through the thirty years which 
followed the publication of that book many observers 
turned their attention to this subject, so that no other 
part of organic chemistry possesses so full a literature 
as this. 



18 INTRODUCTION. 

After this short sketch of the development of our 
subject, it only remains to describe in a few words the 
arrangement of the matter which is here offered. After 
a cursory account of the microscopical construction and 
the function of the urinary apparatus, without a knowl- 
edge of which an understanding of its pathology is 
impossible, the physical properties and the chemical con- 
stituents of the urine will be separately treated, at least 
so far as is important for the practicing physician. A 
description of the microscopical part, viz., the sediment, 
will then be added. The many repetitions which occur 
are suitable rather than blameworthy for the beginner. 

It is to be hoped that the short table for the method 
of investigation will not be useless to the beginner. 
The conclusion is formed of a compendium of the simple 
uncomplicated diseases of the urinary apparatus, as far 
as the indications form valuable signs for their diag- 
nosis. 



CHAPTEK I. 

HISTOLOGY OF THE URINARY ORGANS. 
1. THE KIDNEYS.* 

If one cuts through the kidney from the papilla to 
the fibrous capsule, it is possible to clearly discern with 
the unaided eye a concentric arrangement of layers, i. e., 
the striated medulla and the more granular cortex sur- 
rounding the same. 

If the blood and urinary vessels have previously been 
treated with different-colored injection fluids, it is possi- 
ble to distinguish further subdivisions on the cut surface. 

In the papillae and close upon the same the kidney, 
by injection of the urine-tubes, shows striations ; this 
portion is known as the papillary part of the medulla. 
Above this comes a section which is also striated; but 
the striations alternate with those filled with the colored 
injection fluid of the blood-vessels ; this is known as the 
boundary or limiting layer of the medulla. The third 
and outermost layer surrounding the others is called the 
cortical layer. 

* The investigations of Kolliker, Schweigger-Seidel, and Ludwig, serve 
as the basis for this description of histological relations. 






/ THE UEIXE. 



By tlie colored injection fluids we distinguish the 
two component parts of the cortex. One of : 
stiiated, and contains the injection fluid of the urinifer- 
oufl tubes, which striations are the direct continua:: 
of the straight tubes of the medulla, and are called 
medullary rays (^Markstrahlen), or the prolongations of 




Fig. 1. — Plane section through the kidney of a dog: the urine- and blood-vessels in- 
jected, p, papillary part, and p, boundary or limiting layer of the medulla ; r, cor- 
tex. The dark striations of the medulla. A, are bundles of urine-tubes. The con- 
tinuations of the same into the cortex are the medullary rays, m. The light 
spaces of the medullary portion, 6, correspond to the fasciculi of blooc- 
in the medulla. The light spaces of the cortex studded with dots (glomeruli), 
c, represent the situation of the labyrinth. 



the pyramids : the other part shows principally small 
round bodies (glomeruli), colored by the injection of 
the blood-v and is the so-called labyrinth of 

kidney, or, in a narrower sense, the cortex. 

In support of this, with the mid we find the 

papillary part to be mail- _ th^ 

boundary, pan. .t tubes and partly of - 



HISTOLOGY OF TEE URINARY ORGANS. 21 

blood-vessels ; the medullary rays, principally of straight 
urine-tubes ; and finally the labyrinth, partly of looped 
urine-tubules, and partly of tortuous blood-vessels. 

This system of blood-vessels and urine-tubes is sup- 
ported by a meagre stroma, denser in the medulla than 
in the cortex. On the external surface of the kidney 
this substance becomes a delicate membrane, which is 
loosely adherent to the fibrous capsule. The capsule is 
composed of ordinary connective tissue, with numerous 
fine elastic fibres. It envelops the whole organ, is in- 
serted in the hilus, and, surrounding the blood-vessels, 
sends prolongations to the pelvis of the kidney. 

The urinary tubules have their origin in the laby- 
rinth. Each begins there with a spherical dilatation 
(capsula Malpighii), and " continues as a narrow neck, 
opening to a wider tube, which, after many windings, 
runs toward the medulla. When, as a wide, convoluted 
tube, it has reached the boundary, it suddenly becomes 
of less calibre, and as a narrow canal penetrates more 
or less deeply into the medulla; here the descending 
straight tube turns on itself, forming a narrow loop 
(Henle's loop), and runs directly upward toward and 
into the cortex. On reaching the cortex the canal does 
not seek the place of its origin, but avoids it and runs 
alongside the nearest medullary ray. Sooner or later it 
loses its straight direction, and with several convolutions 
passes as a widened tube (tubulus contortus) among the 
curved canals of the labyrinth. From there it turns 
and enters one of the tubes of a medullary ray (Bellini's 
tubes), the convexity of its curve directed toward the 



22 



ANALYSIS OF TEE URIXE. 



surface of the kidney, thus losing its independent course. 
The latter occurs as follows : Several canals run from 
different directions to the same place and become blended 

K 




Fig. 2. — p, Papilla, g, Boundary, r, Cortex. I, Capsula glomeruli. II, Convo- 
luted portion of tubule passing into III, descending branch of Henle's 
loop, h, Henle's loop. IV, Ascending branch of Henle's loop. V, Con- 
voluted portion of tubule joining VI, tubulus Bellinianus. VII, Another 
tubulu3 Bellinianus. VIII, Common duct. IX, Ductus papillaris. 

into a straight wide tube " (tubulus Bellinianus, Fig. 2) : 
this runs a direct course until it reaches the papillary 
part of the medulla, where it unites with a neighboring 

* The quotations are from C. Ludwig. See Strieker's " Handbook of Histology." 



HISTOLOGY OF THE URINARY ORGANS. 23 

tube and so continues (Fig. 2, VIII.) until the united 
tubes, as the so-called ductus papillaris, empty into one 
of the calices. 

The wall of the capsula Malpighii is made up of a 
mosaic of cells. The glomerulus is not directly sur- 
rounded by the fluid contents of the capsule, this being 
prevented by a layer of nucleated cells not easily de- 
fined, which covers the bunch of blood-vessels. " Be- 
ginning at the neck of the capsule, and extending as far 
as the commencement of the ductus papillaris, the canal 
wall consists of a tunica propria, lined on the inner sur- 
face with epithelial cells." The tunica propria is a ho- 
mogeneous, vitreous, and elastic membrane. 

The epithelium which lines the basement membrane 
is a single layer of nucleated cells. The form of the 
nuclei is always the same, round, sharply defined, and 
showing numerous granules. The body of the cell, on 
the contrary, varies much as regards form. 

In the convoluted tubes the epithelium forms a con- 
tinuous, jelly-like, opaque mass, with imbedded nuclei. 
A division of this mass into cells corresponding to the 
number of nuclei seems impossible. " This epithelial 
pulp lies only lightly upon the basement membrane ; so 
that by making cross-sections of the tube the mass can 
be readily drawn out in a cylindrical form. Micro- 
scopically, fat-globules and other dark granules can be 
seen in this pulp, which is cleared up by addition of di- 
lute acid. Often after the clearing up by acids isolated 
nuclei appear. In the small canals which form the 
arms of Henle's loops appears a thin and transparent 



24 ANALYSIS OF TEE URINE. 

lining epithelium, the cells of which by their nuclei are 
brought into clear relief." 

On the other side of Henle's loops, where the di- 
ameter of the tubes becomes greater, the epithelium 
presents the appearance of true cylindrical cells, which 
are laid over one another as shingles, in a direction 
from the medulla to the cortex. In the tubuli contorti 
we find again the same jelly-like arrangement as in the 
curved tubes leaving the capsulse Malpighii. In the 
straight tubes, even to the ductus papillaris, the epithe- 
lium is built up of a single layer of sharply defined cy- 
lindrical cells, with their broad bases toward the canal 
wall and their blunt points toward the lumen. (PL I., 
Fig. A, 1.) 

The Blood-vessels of the Kidneys. — The arteria 
renaMs sends the greater part of the blood through the 
cortex. Its branches penetrate without forming meshes 
to the limit of the cortex, and here breaks up suddenly 
into very fine arteries, the arteriole interlobulares and 
arteriole rectse. 

The arterioles interlobulares run between every two 
medullary rays. Having reached the layer of convo- 
luted tubules, they give off a small branch to each cap- 
sula Malpighii. This little branch (vas afferent glome- 
ruli') pierces through the ball-like termination of the 
urinary canal (according to others, it only presses in), 
and breaks up here " into a free waving bunch of capil- 
laries (glomeruli), which unite again within the capsule 
to form a common venous stem, the vas efferens glome- 
ruli." This stem leaves the capsule in the same place 



HISTOLOGY OF THE URINARY ORGANS. 25 

that the vas afferens enters. After the vas efferens 
leaves the capsule, "it takes its direction toward its 
own medullary ray, or when this is wanting (as in the 
outermost layer of the cortex), at once toward the con- 
voluted tubes, where it breaks up into a number of ca- 
pillaries, forming a network of anastomosing meshes 
around the tubules." The vasa efferentia communicate 
by means of capillaries with one another throughout 
the cortex, and also with the vessels of the medulla, in 
the same manner. 

The arterioles rectee, which go from the cortex into 
the medulla, have their course in the slit-like spaces 
which lie in the limits of the medulla between the bun- 
dles of urinary tubules, and run to the papillae, in the 
mean time dividing up into several parallel branches. 
When these vessels meet the converging bundles of the 
urinary canals, they break up into capillaries surround- 
ing the urinary tubes, and then are distributed to the 
surfaces of the papillae. This network of capillaries 
communicates with that of the cortex. 

From the above-described capillary nets the venous 
stems arise. In the cortex of the kidney, especially 
in that layer external to the glomeruli, the union of ve- 
nous stems is star-shaped (venae stellatae). The com- 
mon venous stem penetrates that part of the cortex en- 
dowed with glomeruli and medullary rays, lies along- 
side of an arteria interlobularis, and receives numerous 
branches from the cortical network. 

The venules rectee run in the same clefts with the 
arteries, and on the border of the medulla unite with 



•26 AJSTALYSI& OF TEE UEIXE. 

the infi »ming from th^ form gn 

The tlie arteria? 

interlobulares. and partly from other arterial steins in 
ighborhood, viz.. the arteria phreniea. luinbalis. 
and supra-renalis. Their capillaries ran partly into the 
i -f the cortex and partly into the veins 
raiding to the above-mentioned arteries. 
The Nerves of the kidney are supplied by the 
sos coeliacus of the sympathetic Their termina- 
tions in the kidney are unknown. Thev ran alongside 
the great blood-vessels in the same manner as the 
lymph-vessels which empty into the glands of the groin. 



2. THE EXCEETOEY DUCTS. 

The wreterSjpdms. and calieeshave an external fibrous 
coat, a layer of nnstriped muscular fibre, and an internal 
mucous membrane. The fibrous coat is continued into 
the tunica albuginea of the kidney, and is composed of 
ordinary connective and elastic tissue. The muscular 
coat of the ureters consists of three layers. The inner- 
most is composed of longitudinal fibres, the middle of 
transverse, while the external and weakest is again 
made up of longitudinal fibres. In the pelvis the ar- 
rangement is the same. In the calices the muscular 
layers become thinner, and are finally wanting at the 
borders of the papillae. The mucous membrane is thin, 
tolerably vascular, and without glands and papillae. 
The epithelium La in layers, and is characterized by the 
size and form of its elements. The cells in the deep 



HISTOLOGY OF TEE URINARY ORGANS. 27 

layer are round and small ; in the middle layer they are 
cylindrical and spherical, and possess prolongations; 
while in the onter layer they are many-angled and flat- 
tened, and vary considerably as regards size. (PL I., 
A, 2.) 

The Bladder possesses the same arrangement of lay- 
ers. The muscular layer is often considerable, but the 
fibres run so irregularly that a schematic representation 
is impossible. The internal layer is found to be made 
up of a network of circular fibres, which form oblique 
and cross meshes about the neck of the bladder, and 
are in greatest quantity around its mouth, forming the 
sphincter vesicae. Upon these circular fibres lie the 
more external muscular fibres, which run in different 
directions. The trigonum Lieutaudi consists simply of 
a thickening of the layers of connective tissue extend- 
ing from the ureters to the caput gallinaginis. The 
mucous membrane has (except at the trigonum) a dense 
submucous layer, which is tolerably rich in blood-ves- 
sels and nerves, especially at the fundus and neck. In 
the neck and toward the fundus of the bladder are 
found glands formed like bunches of grapes, which 
have a cylindrical epithelium and mucous contents. 

The epithelium of the bladder is of several coats, 
and varies like that of the ureters in its different layers. 
The innermost, which lines the cavity of the bladder, is 
composed of cells which show a more flattened appear- 
ance, but differ greatly in size and shape. The middle 
layer is formed of young cells with conical ends turned 
away from the cavity of the bladder. These prolonged 



28 ANALYSIS OF THE URINE. 

ends often extend into the deep layer. The deep layer 
is composed of irregular oval cells, which, as opposed to 
the middle layer, have their smaller ends in the direc- 
tion of the cavity of the bladder. (PL I., A, 3.) The 
blood-vessels of the bladder are the arteria vesicalis, su- 
perior and inferior, springing from the arteria hypogas- 
trica. These enter the bladder wall at the fundus, 
piercing the muscular layer in an oblique direction. 
Here they give off branches, which break up into capil- 
laries in the layer of connective tissue beneath the epi- 
thelium. The nerves are found in greatest abundance 
at the fundus, in the connective tissue of which it is 
possible to recognize the axis cylinders of their fibres. 
Their terminations are unknown. The blood-vessels 
and nerves of the ureters are similar to those of the 
bladder. 

The Male Urethra has a corpus cavernosum with a 
fibrous coat and loose tissue similar to that of the penis, 
only much more delicate. It has a glandular organ, the 
prostate, which supports it. The mucous membrane 
permits to be seen beneath it a layer of connective tis- 
sue, rich in elastic fibres. External to this are trans- 
verse and longitudinal smooth muscular fibres, both in 
the pars prostatica and membranous portion of the 
urethra. 

The epithelium of the male urethra is composed of 
cylindrical cells (PL I, B, 1), but in the forward half of 
the fossa navicularis we find papillae and pavement epi- 
thelium. The epithelium of the ducts of the accessory 
glands, as the prostate, Cowper's, and Littre's, and that 



HISTOLOGY OF THE URINARY ORGAN'S. 



29 



of the vesicula prostatica, is cylindrical and almost in- 
distinguishable from that of the urethra (PI. I., A, 4 
and 5, and B 7 3). 

The Female Urethra has no bulb ; the mucous layer 
is very vascular, and is lined with pavement epithelium 
(PL I., B, 2 and 3). Only a small number of Littre's 
glands are found. 



CHAPTER II. 

THE EXCRETION OF THE URINE. 

The function of the kidneys consists in the secretion 
of the urine ; that of the bladder and urinary ducts, in 
the gradual collection, retention, and discharge of the 
same. A perfectly satisfactory explanation of the secre- 
tion and excretion of the urine in all its details is 
wanting. 

Bowman advances the theory (in which he is sup- 
ported by the anatomical construction of the kidneys) 
that the epithelial cells are the secretory organs, and 
that from the glomeruli only water escapes, which 
extracts the other constituents of the urine from the 
epithelial cells. 

Ludwig bases his theory upon the varying blood- 
pressure in the renal vessels, and the interchange of 
constituents by osmosis through the animal membranes. 
He assumes that the pressure in the glomeruli is greater 
than in the capillary system immediately surrounding, 
and that consequently a profuse exudation of water 
occurs from the Malpighian tufts, which contains dis- 
solved salts (also blood serum, a little albumen, and fat- 



THE EXCRETION OF THE URINE. 31 

globules). Accordingly, one finds in the urinary canals 
thin urine and in the surrounding capillaries thickened 
blood. These two fluids of such different densities, 
separated by a thin membrane, cause a ready osmosis, 
by means of which water from the urinary tubes enters 
the thickened blood ; on the other hand, the urinary 
tubes receive from the blood the products of retrograde 
metamorphosis (urea and salts). In this manner the 
watery urine becomes more concentrated and richer in 
urea and salts — a true urine. The absence of albumen 
may be accounted for from the fact that it passes 
through animal membrane with much difficulty and 
only under great pressure. Under a pathologically 
heightened blood-pressure in the glomeruli (as stagna- 
tion of the renal venous system), one always finds albu- 
men in the urine, but never under a physiological 
blood-pressure. Though this theory explains many 
physiological and pathological facts, it does not show 
how an acid urine can be secreted from an alkaline 
blood-serum. Hence the mechanical theory of Ludwig 
attributes to the glomerulus a process of filtration, and 
in the further course of the urinary tubes a process of 
osmosis, the office of the epithelium being wholly left 
out of consideration. 

According to Goll and Max Hermann, the difference 
in pressure between the contents of the blood-vessels 
and the urinary tubules constitutes a chief motive power 
which forces the urinary constituents of the blood into 
the urinary tubules. Consequently if the blood-pressure 
in the renal artery is increased, then there is an increase 



32 VLT8L8 OF THE URIXE. 

in the amount of urine secreted; "but if the blood- 
ssnre in the renal artery is diminished, or the pres- 
sure in the ureter approaches the normal blood-pressure 
in the artery, then is the secretion of urine lessened or 
made to cease entirely, long before the pressure in the 
ureter has reached the amount of pressure in the renal 
artery. 

Ustiinowitsch and Griitzner have elaborated these 
theories to such an extent as to demonstrate, by experi- 
ments on the dog, that the secretion of urine is not 
dependent upon the general blood-pressure, but upon 
the local pressure in the glomeruli of the kidney. If 
the medulla oblongata of a dog ,be divided and the gen- 
eral blood-pressure be artificially increased by a current 
of electricity, the secretion of urine is prevented entirely, 
for the reason that the small vessels of the kidney be- 
come contracted. If now the nerves of one kidney be 
divided, there ensues a profuse secretion of urine on 
that side, while no urine flows through the ureter of the 
other kidney. This is due to the fact that by section of 
the vaso-motor nerves of the kidneys the smallest 
arteries become expanded and relaxed, by which means 
the blood-pressure in these small vessels is increased 
and the secretion of urine brought about. Ustimo- 
witsch also shows that by a diminution of the general 
blood-pressure an increase in the secretion of urine 
ensues. If one, for example, cuts through the sym- 
pathetic nerve, which contains the vaso-motor branches 
for the kidney, the blood-pressure in the aorta is 
reduced, but at the same time an expansion of the small 



THE EXCRETION OF TEE URINE. 33 

renal arteries occurs, causing an increase of the urinary 
secretion. 

Heidenhain and Wittich support the theory of Bow- 
man in regard to the secretory function of the epi- 
thelium ; while they prove, by their experiments with 
indigo-sulphate of sodium, urate of sodium, and carmi- 
nate of ammonium, that these substances become sepa- 
rated by the epithelial cells. 

K. Miiller's investigations show that the excretion of 
urine is increased by the application of cold to the skin, 
as fomentations or dressings; but by the application 
of heat, as in a warm bath, or by varnishing the skin, 
the excretion is diminished, the blood-vessels of the skin 
being dilated. A diminution of the quantity of blood 
in the skin capillaries increases the urinary secretion, 
while an increase of the former diminishes the latter. 

According to Wendt, the increase of intra-abdominal 
pressure hinders the excretory process, probably by an 
increase of pressure in the renal veins, by which circum- 
stance, as we know (Ludwig), the secretion of urine is 
checked. 

Maly, Donath, and Posch have proved that, by the 
agency of osmosis, an acid fluid may be obtained from a 
watery solution of several salts (as mono- and di-sodic 
phosphates), which together give a neutral or slightly 
alkaline reaction with litmus. This is a discovery of 
importance, as it obviates the necessity of attributing to 
the renal epithelium the chemical property of acid 
formation. 

Notwithstanding all these theories, there is no hypo- 



34 ANALYSIS OF TEE URINE. 

thesis which gives a perfectly satisfactory explanation 
of all the physiological and chemical processes of urinary 
secretion. We must therefore look upon the excretion 
of urine as a compound process of secretion and filtra- 
tion. 

[The theory of secretion, pure and simple, has per- 
haps gained ground recently owing to the advocacy of 
Heidenhain * and his followers. He accepts the facts, 
abundantly proved by Nussbaum and others, that the 
specific constituents of the urine, such as urea, are 
secreted by the epithelium of the urinary tubules, and 
that the water and salts come from the glomeruli, not 
by mere filtration, but by specific action of the cells 
covering the glomerular tufts. These cells, moreover, 
when in normal condition, prevent the passage of albu- 
men, and only allow it to escape in case of lesion or 
deficient nutrition. Senator, f in our opinion, has, how- 
ever, ably controverted this view as applied to the 
glomeruli, and the separation of urine is to be con- 
sidered now, as when the first edition of this work 
was presented, as a combination of both filtration and 
secretion.] 

[* Hermann's " Handbuch der Physiologie," Bd. V., Part i. 
t " Albuminuria in Health and Disease," and Appendix (1), by Dr. H. 
Senator. " New Sydenham Society Publications," 1884.] 



CHAPTER in. 
\ 

THE VRINE. 



A. A GEXEKAL DESCRIPTION. 

The urine is the secretion of the kidneys, and under 
normal conditions is essentially a solution of such ingre- 
dients as belong to retrograde tissue-metamorphosis. It 
is a solution of urea and chloride of sodium, to which 
are added in less proportion other organic and inorganic 
constituents of the blood, as well as certain foreign 
matters introduced into the organism, which are excreted 
through the kidneys unaltered or having previously 
undergone chemical transformation. 

In a normal condition the urine contains in part 
organic constituents, as urea, uric acid, creatinine, hip- 
puric acid, xanthine, lactic acid, coloring matters, indican, 
grape sugar (Brlicke), [albumen (Senator)], etc. ; part- 
ly inorganic, as chloride of sodium, phosphates of sodi- 
um, magnesium, and calcium, sulphates of the alkalies, 
ammonium salts, iron (as a constituent of the coloring 
matters), and gases — carbonic acid, nitrogen, and oxy- 
gen. In pathological urine, besides the normal con- 
stituents, are found also albumen, grape sugar, inosite, 



ANALYSIS OF THE URINK 

aiy matters, fat. sulphuretted hydi ring 

matters of the blood, uroerythrine leucine, 

and tyi and carl ■alciuni. carbon- 

of ammonium. . pus, blood, epithelium, sper- 

matozoa, fu: . _ ria, 

Before we take into c ition the seme: tic rfg- 

nificanee of the urine, we will describe its peculiarities 

ar as important to our - - subject, and the most useful 
methods of investigation. 



B. PHYSICAL CHAEACTEEISTTCS. 

1. A.mount. 

The amount of urine excreted by a healthy person, 
who eats and drinks moderately, varies between 1,400 
and 1,600 c.c. the mean average for the twenty-four 
hours being 1,500 c.c. 

One passes most in the afternoon, less in the morn- 
ing, and the least at night : for, under ordinary con- 
ditions, in regard to its quantity, the morning urine is 
least influenced by meal- and other circumstances, and 
approaches a mean between the excretions of afternoon 
and night. The urine increases in proportion to the 
amount of imbibed fluids (nrma potus). Its amount 
is increased also, though much less perceptibly, by cold 
and atmospheric moisture, whereby the perspiratio] 

•ned. During rest, or by such circur 
profuse perspiration or profuse diarrhoea, the urine 
diminishes. 



THE URINE. 



37 



2. Specific Gravity, 

The specific gravity of normal urine (1,500 c.c.) is 
between 1-015 and 1*021. When the amonnt of urine 
is lessened, the specific gravity is correspondingly in- 
creased, standing in inverse ratio. Pathologically the 
urine varies between 1*003 and 1*040. Especially im- 
portant are those cases in which we find with a lessened 
volume a lower, and with a greater volume a higher, 
specific gravity. We often find a higher specific gravity 
in mellituria, in the beginning of acute febrile diseases, 
and after the administration of neutral salts. An in- 
creased amount and a specific gravity between 1*030 and 
1*040 is suggestive of mellituria. A lower specific 
gravity is to be observed in hydruria, urina spastica, and 
urina potus. 

The specific gravity is best obtained by means of a 
pyknometer, or by scales ; though for practical purposes 
less complicated means of investigation answer. For 
immediate determination the urinometer is very con- 
venient. 

The surest method of ascertaining the exact specific 
gravity by the urinometer is as follows: One fills a 
small standing glass cylinder tube four fifths full of the 
urine ; the froth being removed by filter paper, the 
urinometer is allowed to sink into the urine guided by 
the supported right hand, never being allowed to come 
into contact with the side of the tube. Bring the eye 
on a level with the surface of the urine, and read the 
division corresponding with this surface (not the upper 



38 ANALYSIS OF THE URINE. 

rini of the fluid raised slightly on the stem by attrac- 
tion). Touch the stem, causing the urinometer to sink 
slightly in the fluid ; and, when it comes to rest, read 
again. 

In all urinometrical observations, the urine should 
have a temperature between 12° and 17° C. ; otherwise 
considerable errors may be made. 

If the amount of urine is small, dilute with even 
three or four volumes of water : test as directed above, 
and multiply the number read off by the 'number of 
volumes made by the dilution. For example : If three 
volumes of water be added to one volume of urine, and 
we read 1*008, to obtain the real specific gravity of the 
original fluid 1-008 is multiplied by 1 + 3 == 4 (1-008 X 
4 = 1-032). The solid materials (on which the specific 
gravity depends) which formerly were dissolved in one 
volume are after the dilution dissolved in four vol- 
umes : the specific gravity is therefore only one fourth 
of the specific gravity of the original ; or, what is the 
same thing, the specific gravity of the original is four 
times the specific gravity of the dilution. 

3. Solid Ingredients. 

In normal urine the solid materials excreted in 
twenty-four hours are generally 60 to 70 grammes. 
Should we find say 200 grms., diabetes is indicated. If, 
on the contrary, we find a very small amount of solids 
excreted, say 20 grms., and the quantity of urine not 
correspondingly diminished, it indicates hydruria. In 



THE URINE. 39 

order to estimate the amount of solid constituents ex- 
creted in twenty-four hours, one can employ either the 
coefficient of Trapp (2), or that of Haser (2-33). (For 
the exact determination, see Chapter V.) By multiply- 
ing the decimal of the specific gravity by the coefficient, 
we have as the result (in grammes) the weight of solids 
contained in 1,000 c.c. of urine. Hence, if we have the 
entire amount passed in twenty-four hours, we can 
easily estimate the weight of solids contained in the 
whole. For example, we have 1,500 c.c passed in 
twenty-four hours, of sp. gr. 1*020 ; to estimate the 
weight of solids in 1,000 c.c, we multiply the decimal 
20 (the last two figures) by the coefficient of Haser, 
2*33 (20X2-33 = 46-60), and the product, 46*60, is the 
weight in grammes of the solids in 1,000 c.c. of the urine. 

Now by the proportion, 1,000 : 1,500 : : 46*60 : x, we 
are able to estimate the amount of solid materials con- 
tained in the excretions of the twenty-four hours. In 
the given example x would represent the unknown sol- 
ids, and x = 69*90, the weight in grammes of the solid 
materials contained in the twenty -four hours' secretion 
of normal urine. 

In the following examples will be considered the 
amount of solids excreted in different urines in the 
course of twenty-four hours : 

Example 1. — Amount of urine, 4,000 c.c. * sp. gr-, 
1*007. 

7X2*33 = 16*31. 

1,000 c.c. of this urine contain 16*31 grms. of solids, 



40 ANALYSIS OF THE URINE. 

and 4,000 c.c. contain 65*24. We see in this example 
that the quantity of solids is normal, but simply the 
amount of fluid has increased. This may be an indica- 
tion of polyuria, or may be entirely physiological, as 
urina potus. 

Example 2. — Amount of urine, 6,000 c.c. ; sp. gr., 
1-013. 

13X2-33 = 30-29, solids contained in 1,000 c.c. 
and as 1,000 : 6,000 : : 30'29 : x, 

# = 181*74 grins. 

In this example we find the amount of solids excreted 
in twenty-four hours to be more than double the nor- 
mal quantity. This urine would consequently suggest 
diabetes. 

Example 3. — Amount, 2,000 c.c; sp. gr., 1*005. 

5X233 = 11*65 
1,000 : 2,000 :: 11-65: x. 

2,000 c.c, contain 23*30 gnns. of solid materials. The 
solids are deficient here in the twenty-four hours' excre- 
tion, and hydruria is indicated. 

The differential diagnosis between diabetes insipidus 
and hydruria on the one hand and urina potus on the 
other, as well as between oliguria and normal urine, can 
be made by an estimation of the solid constituents. 

Besides these, other valuable conclusions may be 
drawn from the amount of solids and the specific grav- 
ity; but each case has a special significance. For 
example, if we have a diseased kidney, the amount of 



THE URINE. 41 

urine normal or diminished, and with a very low spe- 
cific gravity, then we can determine, since nrea com- 
poses nearly half the solid constituents, that there has 
not been a sufficient quantity of the same excreted; 
consequently we may expect uremia, and very soon. 

As the proportion of the solid constituents to one 
another does not remain constant, therefore we can not 
estimate accurately any single one from the specific 
gravity. The variation in the amount of solids may 
be 6 per cent, (in urine with abnormal constituents, 
even more). For example, if we found yesterday 
1,000 parts of urine to contain 50 grms. of solids, and 
to-day 47 or 53, we can not speak positively of an in- 
crease or decrease. 

In judging of the variations of the solid matters 
from the specific gravity, we must further take into 
consideration whether the patient has received his cus- 
tomary amount of food, or (as is the case in all febrile 
processes) has fasted. In the latter case we must regard 
30 grms. as the average. If a person having pneumo- 
nia, placed upon a strict diet, excretes 40 grms. of solid 
matters, we must consider it an increase, and that ac- 
complished at the expense of the feverish body. 

4. Consistence. 

The consistence of normal urine is that of a thin, 
easily dropping fluid. Pathologically it becomes viscid, 
as when there is a great amount of pus in a strongly al- 
kaline urine. The urine becomes stringy, similar to the 



4-2 L73I& *F THE URINE. 

eon: a par-albuminous cyst. If we dilute with 

arbidtty 
ensues, indicating the n alkaline albumi- 

nate, formed by the n of a strongly alkaline urine 

on the ] 

Upon the Isle of 1 urine is often observed 

which soon aftei assage int the 3 as 

lymph i ntains fi brine (fibrinuria). In our lati- 

tude- such urine occurs but seldom, and the condition 
last- I at a moment. TTe have observed temporary fibri- 
nuria in sages of villous tumor of the bladder. In th 

the fluid, of a yellowish-red color and containing a 
slight quantity of blood, thickened after a few moments 

a quivering, jelly-like mass, which old not be 
poured from the re ale. 

If we shake normal urine, a foam appears which 
van:-":-- soon on standing. If the urine contain- sv 
or albumen, the foam remains for a c nsi lerable time. 

for. 

The lor of a normal urine whose gravity 

_ • and amount in twenty-four hours 1 ifl 

wine-yellow. By concenti nes dark wine- 

yellow, then amber-yellow: by dilution it ses through 
pale wine-yeF. I st raw-yellow. Morning urine 
from freely perspirin. reone has always a darker, 
and from urina potus a 1:_ olor. Tl 

of the urine, besides the phya _ ieal changes, is 

rter 



THE URINE. 43 

case the appearance is frequently affected by abnormal 
coloring; matters. 

The urines may be classified according to their de- 
parture from the normal standard of color. 

1. Almost colorless urine. — Especially in neuroses, 
there is sometimes a " urina spastica " produced, and the 
urine can scarcely be distinguished from water. By 
other causes, such as hydruria, as well as diabetes, the 
urine is rendered almost colorless, though the yellow 
color is still recognizable. By standing a few hours 
a light may become a darker urine. Pale urine 
occurs when, with a normal amount of coloring mat- 
ters, the water is increased (as in urina potus, urina 
spastica), or when with a normal amount of water 
the coloring matters are in less quantity (as in granu- 
lar kidneys) ; but in most cases an increase of water 
and lack of coloring matters concur in making the 
urine pale. 

2. Highly colored urine. — These urines are dark yel- 
low with a tendency to red, even to flame-red. This is 
not simply due to a concentration of the urine, but 
often depends upon the presence of uroerythrine. This 
is brought about by acute febrile processes in a stage of 
increase or climax. 

3. Blood-red or garnet-red urine is always caused by 
foreign coloring matters. A number of vegetable mat- 
ters excreted through the kidneys impart to alkaline 
urine a red color. A similar appearance is caused by 
the passage of blood into the urine (for proof of which 
see chapter on abnormal coloring matters). 



44 ANALYSIS OF TUB URINE. 

4. Dark brown to nearly Hack urine is induced by 
rnethaenioglobine from diseases of the kidney, especially 
haemorrhage ; also by the passage of biliary coloring mat- 
ters into the urine (icteric urine), and by the passage of 
coloring matters as yet comparatively unknown ; for ex- 
ample, when colored by long-continued intermittent fever. 

Sometimes, after long standing, urine of melanotic 
cancer becomes almost black ; but, as the coloring matter 
of melanotic cancer has been found in the urine without 
the existence of the cancer, and, vice versa, melanotic can- 
cer being present and the color wanting in the urine, we 
are not able to use this as a means of positive diagnosis. 
After the external use of carbolic acid (for example, Lis- 
ter's dressing), we are apt to find very dark urine, though 
this appearance is not always constant. In children the 
urine is often seen to be colored, after some time, from 
the surface toward the bottom.* In leprosy the fact is 
observed that toward death the characteristic dark-red 
urine becomes dark brown (urorubrohaematine). 

5. Green urine of a dirty hue comes from jaundice, 
and is caused by the presence of biliverdine, having the 
same significance as brown icteric urine. (For a con- 
sideration of biliary coloring matters, see chapter on 
abnormal coloring matters.) 

6. DirtyMue urine. — This shows generally a dark- 
blue film and a similar sediment from indigo. This has 
always an alkaline reaction, and exists chiefly in con- 
nection w T ith cholera and typhus. 

[* This has been seen recently in cases of adults, and proved to have 
been caused by pyrocatechuic or protocatechuic acid. The urine in these 
cases was colored red from the surface downward.] 



THE URINE. 45 

6. Transparency and Fluorescence. 

Normal urine is always clear and transparent, and 
shows after standing some time a mucus-cloud. Micro- 
scopically we find isolated pavement epithelium and 
young cells. The urine of women shows usually a 
denser mucus-cloud (nubecula) and more epithelium 
(generally overlapping), which comes from the vagina. 
Pathological urine may become clouded from any of 
those substances which after long standing form a 
sediment. 

If we desire to prove by chemical means the origin 
of this cloudiness, we proceed as follows : A test tube 
is a third filled with the urine to be examined, and is 
carefully heated over a Bunsen burner or spirit lamp. 

(&.) If the cloudiness disappears, salts of uric acid 
(urates) are indicated, which were suspended in the 
urine on excretion. 

(&.) If the cloudiness increases, on the other hand, 
calcium carbonate, suspended earthy phosphates, or the 
albuminous cell elements (pus, blood) are indicated. 

To distinguish between the above, we add a few 
drops of acetic acid. If the urine clears up, the earthy 
phosphates composed the cloudy precipitate. If, on the 
contrary, it becomes more cloudy, this in most cases is 
due to suspended pus or blood. 

((?.) If it remains unchanged, or we notice after the 
addition of acetic acid a slight increase of the cloudi- 
ness, mucus and bacteria are present in unusual quan- 
tity. 



46 ANALYSIS OF THE UEINE. 

Normal mine shows at times a peculiar white fluo- 
rescence, the cause of which is not exactly understood. 
Alkaline urine shows by reflected light a greenish, by 
transmitted light a yellowish-red, color. Some urines 
show the spectrum of urobiline. 

7. Odor. 

The odor of fresh normal urine is slightly aromatic. 
The cause of this is at present unknown. If the urine 
has become alkaline by standing, we perceive an ammo- 
niacal odor. From destructive processes in the bladder 
we observe frequently a peculiarly repulsive, foul, and 
even fgecal smell. By the use of certain foods and 
medicines, the odor of the urine is strikingly altered. 
For example, asparagus, cauliflower, etc., impart a repul- 
sive smell. Turpentine administered internally induces 
the perfume of violets. The odorous principles of 
cubebs, saffron, and some other substances pass into the 
urine. 

8. Reaction. 

Normal urine possesses an acid reaction, which is 
due especially to the acid alkali-phosphates. The acid 
reaction may be also due to the presence of a free 
organic acid (lactic ?) ; but the part this acid plays is a 
subordinate one. If we add to a fluid containing free 
acid a solution of hyposulphite of sodium, it causes a 
turbidity which occurs instantly or in a few minutes 
(by the separation of sulphur), according to the amount 
of free acid present. If we apply this test to urine, 



THE URINE. 47 

after twenty-four hours there is but a slight precipitate, 
if any. There can consequently be only a small amount 
of free acid in the urine, although this proof is rather 
unsatisfactory. 

Sometimes, directly after a meal, an alkaline urine 
is passed ; but after a few hours this phenomenon disap- 
pears, and it is without clinical significance. 

A strongly acid reaction of the urine is important to 
the physician, inasmuch as it gives rise to the origin of 
certain sediments or concretions which irritate the kid- 
neys and urinary passages (Vogel). 

By standing, an acid urine becomes neutral or 
alkaline. By administration of the alkaline or earthy 
carbonates, or the salts of the vegetable acids (acetic, 
malic, tartaric, etc.), which in the organism become car- 
bonates, an alkaline reaction is imparted to the urine ; 
just as the ammonium carbonate, which is formed from 
urea by the taking up of the elements of water, renders 
the urine alkaline after standing. At first the ammo- 
nium carbonate just suffices to neutralize the urine ; 
consequently the neutral reaction has the same significa- 
tion as the alkaline. 

A strongly alkaline urine may almost always lead us 
to conclude that an affection of the bladder exists — if 
we exclude the formation of the carbonates by decom- 
position. 

The reaction of the urine is usually tested with deli- 
cate blue and red litmus paper. We must observe 
whether the urine is alkaline when it is excreted from 
the bladder, or has become so after its passage, and in 



18 ANALYSIS OF THE UMNK 

what length of time it lias become alkaline ; and further, 
whether the alkalinity is due to the ammonium car- 
the breaking up of urea) or the fixed 
carbon; ken into the body as nourishment or 

medicines ). TTe may determine to which the alkalinity 
is due ; for in the first case, on exposure for some time 
to warm air, the red color of the litnius paper will 
return : but. if the reaction is from fixed alkalies, the 
test paper remains blue after drying. 

net hues we observe urine which colors blue litmus 
paper slightly red, and the red paper slightly blue. 
This reaction is known as amphoteric. It has no satis- 
factory explanation, and is without symptomatic value. 

C. CHEMICAL COMPOSITION. 

a. Normal Organic Constituent*. 

In referring to the constituents of the mine, so 
called, the following table expresses the average quan- 
tity of each excreted in twenty -four hour's : 



Cawnroi 


GEA1DIE5. 


Pee Ce>t. 


Total solids 


60 —7" 
30 —40 
0-4— 0-8 
0-5— 1-0 
0-3— 1-0 
10 —13 
09— 1-3 
2-5— 3-5 
1-5— 2*5 


4*3 —4-6 


Urea 

Uric acid 


2-5 —3-2 
03 —0-05 


Creatinine 

Hippuric acid 

Chlorides 

Earthy phosphates 

Phosphoric arid 

Sulphuric acid 


3§__ 0*062 

0-02 —0-06 
0-7 —0-8 

7 —0-08 
019 —0-22 
0*16 —0-17 



THE UEINE. 49 

We see from this that urea and the chlorides are the 
principal constituents. It is apparent that, if one of 
these matters is wanting or is excreted in diminished 
quantity, it will influence greatly the specific gravity. 
This does not hold true to the same extent with the 
other constituents, which are relatively excreted in very 
small quantity. 

The dissolved gases are of little importance. Car- 
bonic acid gas exists in greatest quantity — 60 to 150 c.c. 
in 1,000 c.c. of urine. Nitrogen is next in amount, 
and there are only traces of oxygen. 

1. Urea. 

Urea, CO N 2 H 4 , is the most constant of all the con- 
stituents of the urine, and exists in greatest quantity, 30 
to 40 grms. being secreted in twenty-four hours by a 
healthy adult. On a flesh diet more is excreted, less 
upon a mixed, and least of all upon a strictly vegetable 
diet. From inanition the secretion may fall to 20 and 
even to 15 grms. In calculating the extent of tissue- 
metamorphosis, if the patient is on a low diet these 
latter figures must be considered the average. 

The simplest way of separating the urea from a 
urine is to throw down the inorganic salts by addition 
of the usual barium mixture, filter, and evaporate the 
filtrate to dryness; extract with common alcohol, filter, 
evaporate the filtrate, and allow the crystals of urea to 
form by adding absolute alcohol and setting aside to 
evaporate spontaneously. Another method is as fol-i 



50 ANALYSIS OF TEE URIXE. 

lows: Evaporate the urine to a tliin simp, and add 
concentrated nitric acid in the cold, whereby the nitrate 
of urea is precipitated. These crystals are now treated 
with carbonate of barium, and the urea is extracted 
from the dried mass by means of alcohol. 

Synthetically urea can be f omied from cyanate of am- 
monium. We fuse 80 parts of anhydrous ferrocyanide 
of potassium with 30 parts of carbonate of potassium in 
a crucible, and the resulting potassium cyanide (KCN) 
is converted into potassium cyanate (KCNO) by oxi- 
dation with 150 parts of red oxide of lead at a gentle 
heat. The white melt is then thrown upon an iron 
plate. After cooling, the potassium cyanate (KCNO) 
is dissolved in a solution of 80 parts of ammonium sul- 
phate ((KH 4 ) 2 S0 4 ) to 500 parts of water. Then by 
decomposition we have ammonium cyanate and potas- 
sium sulphate (NH 4 CNO and K 2 S0 4 ), filter, and evapo- 
rate the nitrate to dryness. During the evaporation 
the relation of atoms is changed, so that from the cya- 
nate of ammonium urea is formed. 



/CN 
°< 


NH, 

C 0/ 

NH 


Cyanate of ammonium. 


Urea. 



The mass resulting from the evaporation is then 
extracted with boiling alcohol, 100 grms. at a time, and 
allowed to crystallize. 

Urea crystallizes microscopically in white, glisten- 
ing needles, macroscopically in long, clear, four-sided 



THE URINE. 51 

prisms, the ends of which are terminated by one or 
two oblique planes. These are very soluble in water 
and alcohol, but insoluble in ether. By heating on 
platinum foil, ammonia is generated freely. If we 
add a solution of urea to a stale urine or to a secre- 
tion from bladder catarrh, in contradistinction to its 
synthetical formation, it decomposes (by taking up one 
molecule of water) to 1 mol. carbonic acid, and 2 mols. 
ammonia (CH 4 N 2 + H 2 = C0 2 + 2NH 3 ). This de- 
composition ensues when urea is boiled with mineral 
acids, fused with caustic alkalies, or heated with caustic 
baryta in a closed tube. With nitrous acid or with 
hypochlorite or hypobromite of sodium, the urea de- 
composes, forming carbonic acid, water, and nitrogen. 

Mercuric nitrate gives with solutions of urea a white 
flocculent precipitate, which, according to the concentra- 
tion and temperature of the fluid, contains two, three, 
or four equivalents of mercury to one of urea. Urea 
also enters into combination with chloride of sodium. 

If we add pure nitric acid to a concentrated 
urine or a concentrated solution of urea, we obtain 
beautiful microscopic and often macroscopic rhombic 
tables. 

If we only have a drop of a fluid containing urea to 
be analyzed, we add a drop of nitric acid on an object- 
glass, and after warming slightly set it aside to crystal- 
lize. With the microscope we see single rhombic or 
hexagonal plates, or we observe them in greater mass 
more or less perfectly formed, arranged in shingle-form 
layers, exhibiting their acute angles (nitrate of urea, 



SB AXALTSIS OF THE UWOR 

PL III.. A, 1> .The acute angle ~ J : . The proof 

by forming nitrate of urea is most frequently used, on 
account of the characteristic shape of the ( 

With albuminuria the nitrate of urea crystallizes 
in penicillated needles. ^K. B. Hofmanu. B Zooche- 
mie. 

Upon the addition of oxalic acid to a concenti i 
solution of urea, crystals are formed which in appearance 
resemble those of urea nitrate (PL III.. A. 1); the for- 
mer crystals, however, appear more irregular in shape 
than the latter. This reaction is only employed to con- 
firm what has been already proven by the nitric acid 
test 

All tests for urea must be applied to concentrated 
urine. If albumen is present, it must be separated by 
coagulation and filtration, and the nitrate concentrated. 

In order to determine that a given fluid is urine, the 
presence of urea and uric acid must be proved. If 
there are only a few drops of the fluid, the micro- 
scopical test for nitrate of urea is to be employed ; but 
it must not be forgotten that transudates may also con- 
tain urea. 

As urea is present in greater quantity than any c 
constituent of the urine, its percentage may be deter- 
mined, at least approximately, from the specific _ 
of the fluid, provided a normal amount of sodium 
chloride is present, no BOgar, and no _ quantity of 

albumen. 

If the urine to be ana' :i tains a normal amount 

of chlorides., neither albumen nor sugar, and ha- 



TEE URINE. 53 

cific gravity of 1*020-1 *024, urea can be said to be 
present in normal percentage (2-2*5 per cent.). 

If, under the above conditions, the specific gravity is 
higher or lower, there will be a corresponding increase 
or decrease in the amount of urea present. If the spe- 
cific gravity is 1*014, the urine contains about 1 per 
cent, urea ; if, on the other hand, the specific gravity is 
1*028-1*030, the urine contains 3 per cent. urea. 

If the chlorides exist in small amount or are inappre- 
ciable, as is sometimes the case with urine of acute 
fevers, and the specific gravity is normal, then urea 
exists in greater than usual percentage. For the chlo- 
rides have a second place (albumen and sugar excepted) 
in influencing the specific gravity, and if these are 
wanting and the specific gravity is 1*020, we know it is 
due to an excess of urea ; for, even if all the other con- 
stituents were excreted in double quantity (as uric acid, 
creatinine, phosphates, and sulphates), they would have 
no appreciable influence on the specific gravity. 

If albumen is present in but small quantity (up to 
0*2 per cent.), which fact we can ascertain approximately 
by the nitric acid test, we need not take it into con- 
sideration; for, if the albuminous precipitate is not 
massive nor curdled, but white, cloudy, and translucent, 
it has no especial influence on the specific gravity. But, 
if the urine contains more albumen (1-2 per cent.), it 
must then be separated by coagulation and filtration. 
For this purpose it is best to take a certain quantity, 
say 50 c.c, and heat to boiling with a few drops of acetic 
acid, filter the urine from the coagulated albumen, and 



54 ANALYSIS OF THE URINE. 

wash with distilled water until we have a volume of 
fluid equal to that at the beginning (50 c.c). We then 
find the specific gravity of this urine freed from albu- 
men. 

Usually albuminous urines have a less specific grav- 
ity than the normal; because, through diseases of the 
urinary organs, the latter are unable to excrete the 
amount of solids (especially urea) that the healthy or- 
gans excrete, and consequently the specific gravity of 
the urine is less. As regards the specific gravity, ex- 
creted albumen is very seldom present in such quan- 
tity as to make up for the want of urea. 

If sugar exists in great quantity in a urine, the per- 
centage of urea is always diminished : although, in the 
total amount of urine excreted in twenty-four hours in 
diabetes, the absolute quantity of urea is increased. 
The high specific gravity of such urine depends upon 
the sugar. 

Notwithstanding certain claims, up to the present 
time urea has not been formed artificially from proteine 
substances ; but we must regard such substances as its 
only source. 

Urea owes its origin in part to the retrograde meta- 
morphosis of tissue (including the blood), and partly to 
the breaking down of the unassimilated nitrogenous 
principles. Whether it arises through gradual oxida- 
tion, whether its molecule is split off from a more com- 
plex molecule by a process of fermentation, whether it 
is a splitting up of the albumen molecule itself, or 
whether a gradual disintegration of the albumen mole 



THE URINE. 



55 



cules leads to the formation of smaller molecules from 
which urea results by oxidation, is up to this time unde- 
cided. 

It is known that certain combinations of the uric 
acid group (uric acid, allantoine, creatine, sarMne, xan- 
thine, guanine) and the known derivatives of the pro- 
teines (glycocoll, leucine, asparagine), when introduced 
in large amount, cause an increase in the quantity of the 
solids excreted. 

Urea may under certain conditions be present in 
such amount that the simple addition of nitric acid to 
the urine forms a thick pulp of nitrate of urea. This 
may take place — 

(1.) From a predominant animal diet. 

(2.) In acute febrile processes, until the crisis of the 
disease. The urea arises in these cases from an in- 
creased disintegration of the nitrogenous elements. 

(3.) In diabetes insipidus and diabetes mellitus. 

[The amount excreted will also vary with the de- 
gree of mental and bodily activity.] 

On the contrary, the amount of urea is lessened — 

(1.) By a predominant vegetable diet, and by fasting. 

(2.) By chronic disease, when the tissue-metamor- 
phosis is checked (cachexies). 

(3.) By parenchymatous nephritis, accompanied by 
uraemia, especially toward the fatal end (7 grms.). 

The percentage of urea is diminished in urina potus, 
urina spastica, and diabetes. But in the whole quan- 
tity of urine passed in twenty-four hours the amount 
of urea is increased, or at least is normal. 



56 ANALYSIS OF THE URINE. 

2. Uric Acid, 

Uric acid (C 5 N 4 H 4 3 ) is a constant constituent of 
the urine of the carnivora. From a healthy man 
0*4-0-8 grin, is excreted in twenty-four hours. 

It is soluble with difficulty in 15,000 parts of cold 
and in 1,800 parts of hot w^ater, insoluble in alcohol and 
ether. It is from these circumstances that uric acid ex- 
ists in but small quantities in the urine in a free state, 
but generally is found in combination as urates. 

In a warm solution of the normal alkali phosphates, 
uric acid dissolves more readily than in water, because 
it takes up from the phosphates a part of the alkali, 
forming an acid alkali phosphate and an alkali urate. 

Free uric acid as well as the urates (salts of uric 
acid) appear colored in the sediment, and the more in- 
tense their color the more highly is the urine colored. 

In order to obtain uric acid from the urine, we add 
one part of HC1 to 20 parts of urine, and let it stand 
twenty-four hours. It appears on the bottom and sides 
of the beaker as a fine powder, and on the surface of 
the urine as a film. The forms of the uric acid crystals 
are wedge- and whetstone-shaped ; i. e., they are rhom- 
boidal vertical prisms. (PL II., A.) It appears in these 
forms as a natural sediment. If the uric acid, however, 
is separated by means of hydrochloric acid (HC1), then 
the crystals are somewhat changed ; they appear much 
thicker and more deeply colored. 

Generally we find under the microscope either dou- 
ble wedges in cross, form, or groups of thin and long 



TEE URINE. 57 

wedges or needles parallel to one another, some of 
which resemble a comb with teeth on either side. Oc- 
casionally we find single long whetstone- or needle- 
shaped crystals. (PL II., B.) If we filter the solution 
containing the uric acid crystals precipitated by HC1, 
and dissolve the crystals in potassium or sodium hy- 
drate (KOH, NaOH), and then precipitate again by 
HC1, the separated crystals are much whiter. Snow- 
white crystals may be obtained by repeating this 
process. (PL II., A.) The crystals of uric acid may 
also be purified by dissolving them in sulphuric acid 
(H 2 S0 4 ) and precipitating by addition of much water. 

In freshly passed urine we should never find a sedi- 
ment of uric acid or urates. If we find this condition 
often, we must suspect stone or gravel. It happens fre- 
quently that with stone or gravel, uric acid may be ex- 
creted in the form of millet and flaxseed concretions, 
which are too large for a microscopic investigation, and 
therefore no sure diagnosis of their constitution can be 
made. In such cases we can very suitably prove the pres- 
ence of uric acid in a chemical way by the murexide test. 

Murexide Test* — For this test rub up the concretion 
in a small mortar, and throw into a porcelain dish ; add 
a few drops of nitric, acid (HN0 3 ) and a little water, 
and warm carefully over a flame until the uric acid has 
dissolved ; then evaporate cautiously almost to dryness. 
Already during the evaporation we notice, if uric acid be 
present, onion-red streaks on the walls of the dish, which 

[* This test can, of course, be applied to the urine itself by evaporating 
a few drops of it and treating the residue.] 



58 ANALYSIS OF THE URINE. 

vanish suddenly as that portion of the dish approaches 
the name. If, when the fluid has evaporated nearly to 
dryness, we add a drop of ammonia to the residue, the 
whole interior of the dish becomes a beautiful purple-red 
color (murexide = acid purpurate of ammonia). If we 
add, on the other hand, a drop of concentrated KOH to 
the residue, we obtain a beautiful violet-blue. The mu- 
rexide reaction depends on the fact that by the addition 
of HN0 3 and heat, first alloxan and then alloxantine is 
formed, which on adding ammonia becomes murexide. 

Instead of the murexide test, we may also dissolve 
the powdered concretions in some caustic potash and 
precipitate with hydrochloric acid (HC1). We can 
easily distinguish the characteristic whetstone crystals 
of uric acid, if it be present, by placing the crystals 
immediately under the microscope. 

If we have but a small quantity of fluid (say 5 c.c.) 
to test for uric acid, we place it in a watch glass with a 
fine linen thread, add a few chops of acetic acid, and let 
it stand twenty-four hours at a temperature of 15° R, 
and observe with the microscope whether uric acid has 
crystallized upon the thread. 

If we add to an alkaline solution of uric acid a weak 
cupric sulphate solution, a white precipitate of a cuprous 
urate falls. If we add a concentrated cupric sulphate 
solution and boil, we obtain a precipitate of cuprous 
oxide free, as a red powder. In the latter case the 
oxide is reduced to suboxide, and the oxygen goes to 
oxidize the uric acid. (In the colorless solution we find, 
besides urea, allantoin and oxalic acid.) 



THE URINE. 59 

Nitrate of silver in the cold is readily reduced by 
an alkaline solution of uric acid. When a drop of the 
silver nitrate on a filter paper is touched with the uric 
acid solution, there results (if there is contained 10 1 00 
per cent, uric acid) a black or (if there is contained 
6 ^ per cent, uric acid) a brownish-yellow spot. 

Uric acid in presence of an alkali is oxidized by 
ozone to urea, ammonia, oxalic acid, and carbonic acid ; 
without an alkali, to urea, carbonic acid and allantoin. 

Uric acid furnishes under the influence of various 
oxidizing agents, besides the customary urea, a great 
number of interesting decomposition products which 
may be regarded as ureas, in which the hydroxyl is re- 
placed by an acid radical. The uric acid itself appears 
to contain the residues of two urea molecules.* 

Uric acid is dibasic, and forms correspondingly two 
series of salts, neutral and acid. 

The neutral salts are readily soluble in water, the 
acid salts with difficulty. One part of the acid urate of 
sodium is soluble in 124 parts of hot and 1,150 parts of 
cold water. Consequently, if we find salts of uric acid 
in the sediment, we know that they are the acid salts ; 
on the other hand, if we have uric acid salts in solution 
after the urine has stood and is of the same temperature 
as the surrounding air, we know that the greater amount 
consists of neutral salts. This view is supported by the 
fact that when we add to such a urine a few drops of a 
strong acid, viz., HC1 or HN0 3 , the urine at first be- 

* (K. B. Hofraann, " Zoochemie," " Abbildungen von Alloxan, Alloxantin, thi- 
onursaurem Ammon, Uramil, Parabansaure.") 



60 ANALYSIS OF TEE URISE. 

comes turbid. If now we examine by the microscope, 
we find no characteristic uric acid crystals, but we see 
simply an amorphous punctif onn mass, which consists of 
the acid urate of sodium. If we allow the urine con- 
taining the turbid cloud to stand for some time, the 
cloud gradually disappears, and in its place we find a 
distinct crystalline sediment of free uric acid. This 
reaction can not be more amply explained than that, 
having found neutral uric acid salts in solution, we have 
changed them to acid urates precipitated as a cloud, by 
the addition of an acid ; for the added acid has taken up 
some of the alkali of the soluble neutral urates, and 
transformed it to acid urates. The acid by a longer 
action on these takes up the rest of the alkali, and the 
uric acid crystallizes. 

It must be remembered that when the test for albu- 
men is performed by pouring HX0 3 down the side of a 
wine glass, between the two fluids which do not mix 
there appears a thick white cloud, often mistaken for 
albumen, but consisting of amorphous acid urates, which 
by longer standing pass over into crystalline uric acid. 

The acid urates of sodium and ammonium will be 
described later, in connection with the sediment. The 
causes of the increase or decrease in the amount of uric 
acid in the urine have not as yet been satisfactorily ex- 
plained. 

Uric acid is recognized as the first step in the forma- 
tion of urea, although it is not probable that all the urea 
in the body passes through this stage. By the accept- 
ance of this would be explained the increase of uric acid 



THE URINE. 61 

in all those cases where the oxidation of the nitrogenous 
products is insufficient ; it may be that either too little 
oxygen has been introduced into the organism, or too 
much uric acid has been formed to be oxidized by the 
amount of oxygen present. There are many facts, how- 
ever, not in accordance with this explanation. 

Uric acid, as a derivative of proteine matters, has a 
similar significance to urea, as regards tissue-metamor- 
phosis. We will therefore generally find an increase of 
uric acid where urea is excreted in greater than normal 
quantity. 

We find, in accordance with this, an increase of uric 
acid — 

(1.) From rich animal as well as vegetable diet, and 
too little exercise in the fresh air. 

(2.) In acute febrile processes, which cause much 
breaking down of the nitrogenous elements of the body. 

(3.) In lung and heart diseases, with dyspnoea. 

(4.) In all cases where the diaphragm is impeded in 
its function, i. e., as with large tumors of the abdomen, 
ascites, etc. 

(5.) In leucaemia, either with an increase of uric acid 
in the diseased spleen, or with diminished oxidation 
power of the red corpuscles, the carriers of oxygen — 
impoverished blood. 

(6.) With the so-called uric acid cachexy. 

A decrease of uric acid occurs usually in chronic af- 
fections of the kidney, diabetes mellitus (sometimes), 
urina spastica, hydruria, and arthritis. 

The amount of uric acid in the urine may be ap- 



62 ANALYSIS OF TEE URINE. 

proximately determined in the following way : Nor- 
mal urine, of specific gravity 1-020-1/024, shows in 
the sediment neither uric acid nor the urates at the 
normal temperature, nor is there a precipitate with 
nitric acid. 

If we concentrate a normal urine, we observe a small 
amount of free uric acid in the sediment, and by means 
of the nitric acid test a delicate layer of urates is seen. 
If in these cases the specific gravity is high, the urea is 
increased, as is also the uric acid. If we find with the 
normal amount of urine a considerable " brick-dust " 
sediment and also urates in solution, or if we find a con- 
siderable sediment of free uric acid, then the amount of 
uric acid may be considered as large. If the amount of 
urine is less than normal, we can not draw this conclu- 
sion. In this case we may have a sediment from the 
normal amount of urates, if the amount of water is not 
sufficient to hold them in solution at the usual tempera- 
ture. 

In general, whenever the urea is in less quantity, the 
uric acid is also diminished. All that has been said 
refers only to the percentage. If we wish to estimate 
the entire amount excreted, we must take into considera- 
tion the amount for twenty-four hours. It is most ad- 
vantageous to compare with the normal urine. The 
average amounts to 1,500 c.c, and we have to add as 
much water to the concentrated urine as will bring the 
amount to this standard. If in twenty-four hours only 
1,000 c.c. has been passed, we must add 500 c.c. of water, or 
what is the same thing, to every 10 c.c. of urine 5 c.c. of 



THE UjRIJSTK 63 

water. We pour into one of two narrow test-tubes 
15 c.c. of normal urine, and into the other 10 c.c. 
of the urine to be examined and 5 c.c. of water, and, 
after adding 10 drops of HN0 3 to each, set them 
aside for twenty-four hours. From the amount of 
uric acid precipitated, one can easily estimate whether 
there is more or less uric acid precipitated in the urine 
to be tested than in the standard urine. If more than 
the normal amount of urine has been excreted in 
twenty-four hours, there must be a corresponding dilu- 
tion of the standard urine. 

[Garrod, in the Lumleian lectures for 1883,* takes 
strong ground in favor of the formation of uric acid by 
the kidney epithelial cells from nitrogenized material 
brought to them. He holds that uric acid exists in 
the kidney as urate of ammonium, and is converted 
into urate of sodium in the presence of excess of sodium 
salts in the blood and urine. He considers that the 
amount of uric acid in the urine is not increased by 
simple sugar (whether as glucose, cane sugar, or lactose), 
or fruits containing acid vegetable salts (as cherries, 
apples, and strawberries), or by light wines and dis- 
tilled spirits, but is increased by sweetened fruit, 
heavy wines, and malt liquors. He attributes these 
results to a a ferment."] 

3. Coloring Matters. 

In normal urine there is a chromogenous matter (in- 
dican) and a pigment (urobiline); and several other 

* " British Medical Journal," March 17, 1883, et seq. 



64 ANALYSIS OF THE URINE. 

well-characterized bodies are found in the urine, as well 
as one or more pigments which have not been satisfac- 
torily isolated. 

a. JJroliline. Urobiline is a brown resinous mass 
which is easily soluble in water, more readily in 
alcohol, ether, and chloroform. The concentrated so- 
lutions are brown; by dilution they become yellow, 
and finally rose-red. They do not react upon litmus, 
show in reflected light a beautiful green fluores- 
cence, and in the spectrum a dark absorption band 
between Fraunhofer's lines b and F. The fluores- 
cence and absorption band become more distinct if 
we add to the solution some ammonia and a drop 
of chloride of calcium. By the addition of hydro- 
chloric acid (HC1) the fluorescence vanishes. By 
acidifying the urobiline solution the absorption band 
recedes toward F, becomes paler, and shows more in- 
distinct edges. If we add ammonia to the acid solu- 
tion, the brown or red color changes to bright yellow 
with a greenish tinge. The alkaline solution shows 
the absorption band in the same place (if anything, 
nearer to b) as the original solution. 

Dark fever urine is better suited for the separation 
of urobiline than normal urine. The latter involves 
too much work. We render the urine strongly alka- 
line with ammonia, filter after some time, and add 
chloride of zinc solution as long as a precipitate is 
formed ; wash the precipitate upon a filter with cold, 
then with hot water, until nitrate of silver solution 
causes no turbidity ; boil the mass with alcohol, 



TEE URINE. 65 

dry at a gentle heat, dissolve the powdered mass in 
ammonia, and precipitate the solution with lead ace- 
tate ; wash the precipitate with a little water, and take 
it up in a small amount of alcohol containing some 
sulphuric acid, and filter again. To the filtrate we add 
an equal volume of chloroform, and shake, adding 
fresh volumes of water to separate the sulphuric acid, 
until a color is perceived. The urobiline is obtained 
as a resinous mass by evaporating the chloroform. 

Urobiline is, according to Maly, a reduction prod- 
uct of bilirubine. Hoppe-Seyler has succeeded in 
obtaining a product identical with urobiline (Maly's 
hydrobilirubine *) from the coloring matter of the 
blood, by treating with hydrochloric acid and tin. 
By injection of substances which cause the break- 
ing up of the blood corpuscles, the formation of 
bile-coloring matters is promoted; so it is hardly to 
be doubted that urobiline is a secondary or direct 
reduction product of hsemoglobine, and that its in- 
crease possesses an interest for the physician. Such 
a condition is found in febrile processes, and indi- 
cates therefore a greater breaking down of the red 
blood corpuscles. 

Urine which, on addition of ammonia and a little 
chloride of zinc solution, shows a green fluorescence 
and the characteristic absorption band, should be re- 
garded as moderately rich in urobiline. 

Scherer's urohsematine, Heller's urophseine, Thudi- 

* See " Annalen der Chemie," 163, p. 77, and Hofmann, " Zoochemie," 
p. 220. 

5 



66 ANALYSIS OF THE UBWE. 

chum's urochrome, etc., are bodies for whose existence 
as proximate principles there is no guarantee. Maly 
has shown further that urochrome and urohsematine 
both contain much urobiline. 

fi. Indican. More recently Heller has shown that, 
by the mixing of the urine with nitric acid, a peach- 
blossom red, violet, or deep-blue color appears. The 
red he ascribed to urrhodine, the blue to uroglau- 
cine; and the base from which both arise, and which 
he regarded as a yellow coloring matter, he called 
uroxanthine. Uroglaucine is found in spontaneously 
putrid urine, in the sediment, or as a film on the sur- 
face. This has been recognized as indigo, in that it 
is identical with plant-indigo in all its peculiarities 
(crystallizing in needle form, subliming as a red vapor, 
and being deprived of color by reduction agents, as 
sulphate of iron). 

Uroxanthine was regarded as identical with indi- 
can, a derivative from which is white indigo, which is 
found in some plants. Later investigation has ren- 
dered it probable that the indigo-producing substance 
of the urine differs from plant-indican. We will call 
it urine-indican. 

If we do not desire a large quantity of pure urine- 
indican, we may precipitate fresh urine with neutral 
and basic lead acetate, treat the filtrate with ammonia, 
suspend this precipitate in alcohol, and permit a stream 
of hydrogen sulphide to pass through ; filter from the 
sulphide of lead, and evaporate with a gentle heat, 
finally, over sulphuric acid in vacuo. The urine-indican 



THE URINE. 67 

thus obtained is a pale brown, bitter-tasting sirup. By 
a more complicated method we can obtain it in quan- 
tity. (Hoppe-Seyler, " Chemische Analyse," 4th edi- 
tion, p. 191.) 

The urine-indican is not a glycoside, as by splitting 
up (contrary to older writers) it yields no sugar 
(indi-glucine), but is a sulpho-conjugate compound of 
iudol, because by addition of HC1 a large amount 
of H 2 S0 4 is liberated (Baumann). In a free state 
this acid ether is unstable, and decomposition as well 
as the action of mineral acids splits it up. In both 
these cases an oxidation takes place; consequently 
the formation of indigo does not consist in a simple 
breaking up. One product, as we have before shown, 
is indigo ; the second is a red body, the sublimate of 
which condenses as fine red needles, and may be identi- 
cal with Heller's urrhodine. On the different propor- 
tion of both decomposition products depends the color, 
which the addition of HC1 to the urine brings about. 

If concentrated sulphuric acid (H 2 S0 4 ) is mixed 
with a double volume of urine (which should be 
dropped in from some height), the mixture assumes 
a more or less garnet-red color, probably due to vari- 
ous decomposition products.* When present, sugar, 
albumen, and biliary matters, as well as their decom- 
position products, undoubtedly take part in this color 
formation, in which case the mixture becomes quite 
opaque and dark brown. (Heller's urophseine test.) 

[* If the patient has taken naphthalene, a green color may result. This 
fades to a dirty-gray or brownish-green. — Benzoldt.J 



68 ANALYSIS OF THE URINE. 

By the mixture of H 2 S0 4 with the urine, a strong 
heat is evolved, which causes the separation of several 
constituents, as iodine, the odorous oil of cubebs, and 
saffron, etc., which are perceived by the smell. In 
parenchymatous inflammation of the bladder a repul- 
sive odor is developed. 

There are many methods of proving the easy chemi- 
cal decomposition of urine-indican in the urine. The 
oldest is the uroxanthine test of Heller, already men- 
tioned. 

(1.) The uroxanthine test is as follows: Pour 3 or 
4 c.c. of pure HC1 into a small beaker glass, to 
which while stirring add 10 to 20 drops of urine. 
In a normal proportion there exists only enough 
urine-indican in the urine to color the hydrochloric 
acid mixture a weak yellowish -red. A greater propor- 
tion colors the HC1 mixture violet or blue. The richer 
a urine is in indican, the more intense will be this color 
reaction. Often one or two drops of urine suffice to 
color 4 c.c. of HC1 a beautiful blue. If in one or two 
minutes no color appears, the urine-indican is not ex- 
cessive, even if in ten or fifteen minutes a dark red- 
brown color appears. 

If we wish to test an icteric urine for indican, we 
must first remove the bile-coloring matters by lead 
acetate, and test the filtrate for urine-indican, though 
some is lost by this method. 

The color of the uroxanthine test has unfortunately 
little value, as it not only indicates the amount of 
urine-indican, but also its capability of decomposition, 



TEE URINE. 69 

which seems to vary. How varying this is, is shown 
by the circumstance that the urine-indican contains 
sometimes more indigo-blue and sometimes more in- 
digo-red. It must be observed also that albumen, 
when treated with HC1 after standing a long time, or 
by heating, develops a violet color. The dark blue 
color, despite the faults that may be attributed to this 
method, can be regarded as a sure indication of an in- 
crease of urine-indican. 

(2.) Jaffe's test — Mix 10 c.c. of strong HC1 with an 
equal volume of urine, add a drop of a saturated solu- 
tion of so-called bleaching powder, or some chlorine 
water, and observe the color. 

(3.) Stohvis's test — Warm 5 c.c. of urine with twice 
the amount of common nitric acid (to 60-70° R.), and 
shake with chloroform, which takes up the indigo. 
The chloroform shows in the spectrum the character- 
istic band of indigo between C and D. 

Here we will simply refer to an interesting method 
of E. Salkowsky (Virchow's "Archiv," Vol. 68, p. 
407). If indol is introduced into the organism, the 
amount of urine-indican excreted will be increased. 
The same follows if the small intestine be ligated 
so as to destroy its permeability; for now by pan- 
creatic digestion (in the latter stages) much indol 
will be formed. This is evidently reabsorbed into 
the blood from the ligated intestine, and is there 
changed into urine-indican, just as is the injected 
indol. The albumen of food is also a source of in- 
dican; for indol is one of the ordinary decomposi- 



70 ANALYSIS OF THE URINE. 

tion products of albumen. It is probable, on the 
other hand, that a portion of the albumen in the liv- 
ing body is decomposed by fermentation, just as out- 
side the body it is destroyed in very much the same 
manner. The albumen of the tissues of the body 
is another source of indol, and consequently of in- 
dican. It is hence evident that by starvation indi- 
can does not disappear from the urine, because it is 
formed at the expense of the disintegrating tissues. 

We find an increase of urine-indican after the intro- 
duction of indol, after an exclusively flesh diet, in Addi- 
son's disease, in cholera, and in carcinoma of the liver ; 
and it is enormously increased in all those diseases 
which threaten closure of the small intestine (incar- 
ceration), but not so much by impenetrability of the 
large intestine. It is considerably increased with car- 
cinoma of the stomach without tbe intestines being 
involved ; also with peritonitis. With kidney diseases, 
except granulated kidney, the indican is not much in- 
creased ; and with chlorosis and leucaemia there is no 
increase. In general there is an increase in chronic 
consumption and in inanition. Fevers do not cause so 
marked an increase of indican as of urobiline. 

There is an increase of urine-indican in central and 
peripheral diseases of the nervous system, as well as 
after the administration of certain drugs, as turpentine, 
nux vomica, oil of bitter almonds, etc. This, however, 
is only demonstrated by the uroxanthine reaction, and 
requires confirmation by more accurate methods. 

[M. Thorns (as quoted in the Boston " Medical and 



THE URINE. 71 

Surgical Journal," August, 1882) reports that urine 
containing balsam copaiva gives, upon the addition of 
hydrochloric acid alone, or with the addition of a drop 
or so of nitric acid, a reddish- violet color similar to that 
produced in urine containing indican. In the former 
case, however, alkalies change the red color to green.] 



4. Other Normal Organic Constituents. 

The remaining organic constituents of the urine we 
will only mention in passing, for they are of little 
value in general diagnosis, because of the care required 
for their identification and separation. 

Creatinine, the strongest recognized base of the 
body, is excreted in the same proportion as uric acid ; 
for a sound man, 0*6-1*3 grm. in twenty-four hours. 
The amount is found to be less by a vegetable than an 
animal diet. It is increased in pneumonia, intermittent 
fever, and typhus, but diminished by inanition and ad- 
vanced kidney affections* 

Hippuric acid is present in largest amount in the 
urine of herbivora, and in only small quantity in the 
human urine, being for a healthy man 0*5-1 grm. in 
twenty-four hours. The amount is increased by a vege- 
table diet, after the use of certain fruits (greengages, 
whortleberries, etc.), and after the use of benzoic acid, 
etc.; also in febrile processes and in diabetes. It is 
diminished by a strict flesh diet. If the excreted mass 

[* It is diminished with paralysis, but increased if there is muscular 
agitation. Grocco, " Ladd. Med. Record," February 15, 1887.] 



72 ANALYSIS OF THE URINE. 

is considerably increased, as after eating greengages, 
and we then evaporate slightly and add HC1, hippuric 
acid will be precipitated in the same manner as uric 
acid. Otherwise we must employ the method of Meiss- 
ner (Neubauer-Vogel, 1. c. 43), for which a litre of urine 
is necessary. 

Xanthine and the phenolsulphate derivatives are 
found in the urine, but in small quantity. For a quan- 
titative determination of the first it is necessary to 
obtain several hundred litres of urine. The existence 
of the substance yielding phenol derivatives betrays 
itself by the phenol reaction of the distillate, if we 
previously acidify the urine with a strong mineral acid 
(e. g., HoS0 4 ). From the fact that when we add 
tartaric acid and distil we have no phenol reaction 
in the distillate, we conclude that phenol (carbolic 
acid) does not exist normally in the tree state in the 
urine. 

We mention in passing that up to this time, from 
a derivative of uric acid, oxaluric acid has been 
found in but very small quantity (not less than a hun- 
dred litres must be used to test for it). Parabanic 
acid occurs as an oxidation product of uric acid, 
and by taking up water becomes oxaluric acid. 
This boiled with water forms oxalic acid and oxalate of 
area 

Oxalic acid is found in the sediment as calcium 
oxalate. 

In regard to the existence of sugar in normal urine, 
the point is as yet undecided. In every case normal 



THE URINE. 73 

urine contains besides the urates a body which in an 
alkaline solution will reduce the copper salts. 

The assertion that lactic acid is present in normal 
urine needs confirmation. In pathological urine we find 
two kinds of lactic acid. One is present in fermenting 
diabetic urine (lactic acid); the other is found after 
phosphorus-poisoning, with acute atrophy of the liver, 
with osteomalacia and trichinosis (paralactic acid). 

b. Normal Inorganic Constituents. 
1. Chlorides. 

In human urine the chlorides consist almost entirely 
of the chloride of sodium (NaCl) and a little chloride 
of potassium. The average excretion for a healthy man 
is 10 to 16 grms. of NaCl in twenty-four hours (6 to 10 
grms. chlorine). Next to urea, NaCl is the principal 
constituent of the urine. Normal urine has an appre- 
ciably salty taste proportionate to the quantity of the 
contained NaCl. If a drop of urine is carefully evapo- 
rated on an object-glass, we find under the microscope, 
besides the colorless monoclinic prisms of the double 
compound of urea with chloride of sodium, also NaCl 
in flat octahedra or in imperfectly shaped crystals of 
the monometric system. 

For the physician it is often important to ascertain 
quickly and easily whether in the urine the chlorides 
are increased or not. An approximative test is the fol- 
lowing (for more exact determinations see Chap. V.) : 

If a chloride of sodium solution is treated with 



74 ANALYSIS OF TEE URINE. 

nitrate of silver, a white precipitate of chloride of silver 
will fall: 

NaCl + AgN0 3 = NaN0 3 + AgCl. 

If we have a solution in which both the chlorides and 
phosphates are present (viz., urine), we must first acidify 
with a few drops of nitric acid (HN0 8 ), so that the 
phosphate of silver will not be precipitated at the same 
time, and thereby be mistaken for the precipitate of 
chloride of silver. A slight error from the precipitation 
of uric acid can not be avoided, but it does not essen- 
tially affect this approximative examination. 

The HN0 3 added will not prevent the precipitate of 
the chloride of silver (AgCl), but it will prevent the 
phosphate of silver from coming down. If we use for 
this reaction a solution of nitrate of silver of definite 
strength (AgN0 3 ), 1 : 8, we will find that, by adding a 
few drops of this to normal urine (which contains |-1 
per cent. NaCl), curdy masses of AgCl will fall to the 
bottom. These masses do not separate on shaking the 
glass, and give no milky cloudiness. If the solution 
contains but a small quantity of NaCl, T ^ per cent, or 
less, the solution after addition of AgNG 3 shows no 
white curdy precipitate, but a simple cloud, and the 
entire fluid shows a homogeneous milky turbidity. 

To apply this test, we take a wine-glass half full of 
urine, acidify with HN0 8 to prevent the phosphates 
coming down, and then add one or two drops of the 
standard AgN0 3 solution. If the reagent causes a curdy 
precipitate readily falling to the bottom, the chlorides 



THE URINE. 75 

are in no way diminished in quantity. If only a milky 
turbidity arises, and no curdy masses, then the chlorides 
are in very small proportion. If there is no milky cloud 
or turbidity, the chlorides are entirely wanting. We 
can not ascertain an increase of chlorides by this 
method. 

This reaction can be seen in a urine that has been 
tested for albumen with HN0 3 , using this mixture for 
the chloride test. The nitric acid must, however, be 
thoroughly mixed with the urine by means of a glass 
rod before adding the silver salt. But, if albumen has 
been found in such amount as to interfere with the cloud 
or precipitate of the chlorides, it must first be filtered 
off before testing with AgJST0 3 , and the test can be 
applied to the filtrate. 

We find a smaller proportion of chlorides in the 
wrine — 

(1.) In repose of the body (in the night-time 
least). 

(2.) With all acute febrile processes, especially when 
accompanied by serous exudation or watery diarrhoea. 
The mass of chlorides is directly proportional to the 
amount of urine, but inversely proportional to the 
specific gravity and the quantity of urea, until the crisis 
of the disease. In general only the excess of chlorides is 
eliminated by the kidneys. In inflammatory processes 
the chlorides appear in the exudates (for instance, in 
pleuritic effusions). In general the rule applies, that 
with a steady decrease of chlorides in the urine there is 
a heightening of the disease, and on the other hand a 






76 ANALYSIS OF THE URINE. 

continued increase of chlorides signifies a better con- 
dition. 

In pneumonia the chlorides may be entirely wanting, 
but we can not attribute this condition to lessened nu- 
trition alone. In typhus and meningitis they are dimin- 
ished, but do not disappear. The absence of chlorides 
always signifies a desperate condition. 

(3.) In chronic affections accompanied by impaired 
digestion, and in dropsy. 

In urina potus the percentage of chlorides is dimin- 
ished ; but, if we take the twenty-four hours' amount 
into consideration, the diminution is inappreciable. 

An increase of chlorides is observed — 

(1.) With a liberal salt diet. 

(2.) With energetic bodily or mental exercise. 

(3.) In the paroxysms of intermittent fever, some- 
times a little before or after the same. The day after 
we find the average daily amount sometimes a little 
less. 

(4.) With diabetes insipidus. 

(5.) With dropsy, as soon as diuresis comes on, for 
now the chlorides stored up in the body become sud- 
denly excreted. 

2. Phosphates. 

The amount of excreted phosphoric acid (not phos- 
phates) is between 2*3 and 3*8 grms. (average 2*8). In 
robust men the average is 3*5 grms. The daily varia- 
tion may be very considerable. The amount excreted 
increases after breakfast until evening (maximum), and 



THE URINE. 77 

falls during the night till the next morning (mini- 
mum). 

We find an increase of phosphoric acid in the 
urine — 

(1.) After the introduction of phosphorus, phospho- 
ric acid, or soluble phosphates into the organism. 

(2.) After a principally animal diet, and especially 
after the administration of such substances as contain 
more or less phosphoric acid, as the brain. 

(3.) With all acute febrile diseases (not constant). 

We find a decrease of phosphoric acid — 

(1.) In all urines of a low specific gravity, in urina 
potus, in urina spastica, etc. 

(2.) In kidney and heart diseases, with a less 
amount of urine. 

(3.) With severe disorders of the digestion, and 
with chronic diseases of the brain (except epilepsy). 

Orthophosphoric or ordinary phosphoric acid (H 3 
P0 4 ) is a tribasic acid ; that is, the three atoms of hy- 
drogen may be replaced by a metal. 

In the urine phosphoric acid is combined partly 
with the alkaline earths (earthy phosphates) and partly 
with the alkalies (alkali-phosphates). 

a. The earthy phosphates — viz., calcium and magne- 
sium phosphates — exist in normal urine only in small 
quantities. The twenty-four hours' average for a 
healthy, robust man amounts to 0-9-1-3 grm. The pro- 
portion of the calcium to the magnesium phosphate is 
as 33 : 67 ; that is, the amount of magnesium is double 
that of the calcium phosphate. In acid urine these 



78 



ANALYSIS OF THE URINE. 



salts are in solution, but in alkaline urine they are pre- 
cipitated, and are found in the sediment. 

Phosphoric acid forms with calcium three salts, viz, : 



The normal 
or tricalcic, 



The dicalcic 
phosphate, 



The monocal- 
cic or su- 
perphos- 
phate, 






g>Ca = Ca,(P0 4 ), 



PO^ o 



o> 



roH 

F0 \ £|>Ca+2H 2 = CaHP0 4 +2H 2 



(OH 
PO-^ OH 



°> Ca+H 2 0=(P0 4 H 2 ) 2 Ca+H 2 



PO^ OH 
OH 



In the urine we find this last combination dissolved 
— no monomagnesic phosphate is known. In the urine 
the dicalcic and magnesic phosphates are held in solu- 
tion by free acid (?). 

The precipitation of the earthy phosphates is brought 
about by the addition of the alkalies (potassium, so- 
dium, and ammonium). 

The reactions of the salts are as follows : If alkalies 
be added to calcium phosphate, it will be deprived of 
some of its acid : 

3[(P0 4 H 2 ) 2 Ca] + 12KOH = 

(P0 4 ) 2 Ca 3 + 4K 3 P0 4 + 12H 2 



THE URINE. 79 

If acid magnesium phosphate is acted upon by ammo- 
nia, an ammonium-magnesium phosphate is formed : 

MgHP0 4 + NH 3 + 6H 2 = Mg(NH 4 )P0 4 -f 6H 2 

Ammonium-magnesium phosphate formed in this 
way appears under the microscope as fern-leaved or 
snow-flake crystals; after long standing in the glass, 
these crystals become coffin -lid-shaped. (PI. III., B.) 

To test for the earthy phosphates, we fill a test-tube 
one third full — if it was not clear with previously filtered 
urine — add a few drops of KOH or (NH 4 )OH, and 
warm until the earthy phosphates separate out as a floc- 
culent precipitate. After setting aside for ten to fifteen 
minutes to settle, we can approximatively estimate the 
amount. If we employ for the reaction an ordinary- 
sized test-tube, 16 centimetres long and 2 c. wide, a 
layer of earthy phosphates 1 c. high corresponds to the 
normal amount in the urine ; if the layer is 2-3 c. high, 
then are the earthy phosphates increased ; if, on the con- 
trary, only single flakes appear, then the earthy phos- 
phates have diminished. 

Beneke gives a more accurate method of determina- 
tion (Neubauer-Vogel, " Analyse des Harnes," Ed. vii., 
p. 91, 1). 

If the urine contains no abnormal coloring matters, 
the earthy phosphates are white ; if abnormal coloring 
matters are present, they are variously colored. If the 
urine contains blood-coloring matters, then the precipi- 
tate appears blood-red or dichroic ; with the plant-color- 
ing matters of rheum, senna, etc., rose-red to blood-red ; 



80 ANALYSIS OF TEE URINE. 

'with bile-coloring matters, yellow-brown; with uroery- 
thrine, gray. 

An increase of earthy phosphates in the urine is found 
with disease of the bones, especially when diffuse (os- 
teomalacia, rachitis, etc.), with diffuse periostitis, and 
with chronic or arthro-rheumatic processes; further, 
after use of mineral waters rich in calcium, after vari- 
ous medicaments, and with exclusive flesh diets (in 
the latter case not constant). 

A decrease of earthy phosphates is observed in kid- 
ney affections. In alkaline urine we naturally find the 
earthy phosphate in the sediment. 

(3. The alkali phosphates are represented chiefly by 
the acid phosphates of sodium and (traces of) potassium. 
The tribasic phosphoric acid forms three salts with the 
alkalies, in which one, two, or three atoms of hydrogen 
are replaced by the alkali metals — 

P0 4 H 2 Na P0 4 HNa 2 P0 4 Na 3 

Monosodic or \ , Disodic or ) c Trisodic or ) e 

Acid sodium f P Neutral sodium j ^ ' Basic sodium f v 

Of these three, only the first has an acid reaction, and 
its presence in the urine causes more than any other 
constituent the acid reaction of the same. Both the 
others have an alkaline reaction. All three are (in 
contradistinction to the earthy phosphates) easily solu- 
ble in water and alkaline fluids. 

Of the total phosphoric acid in the urine, two thirds 
is in combination with the alkalies. 

We test for the alkali phosphates (chiefly for the 
phosphoric acid) in the urine with the magnesium mix- 



THE URINE. 81 

ture. (See Chapter IV., No. 10.) If we test for the 
entire amount of phosphoric acid — that is to say, not 
only that in combination with the alkalies, but also with 
the alkaline earths — we take a beaker of 20 c.c. capacity, 
and to 10 c.c. of urine we add a third part (usually 
3 c.c.) of the magnesium mixture. There is formed a 
precipitate of crystalline ammonium-magnesium phos- 
phate (fir-twig or snow-flake), with which comes down 
an amorphous mass of calcium phosphate. If there 
ensues through the entire fluid a milky turbidity, 
the alkali phosphates are in normal amount; if we 
have a copious precipitate which gives the fluid the 
appearance of cream, then there is a great increase ; 
if the fluid remains transparent, or only a slight tur- 
bidity ensues, we have a decrease of the alkali phos- 
phates. 

This reaction is more for the whole amount of 
phosphoric acid in the urine than for the alkali 
phosphates. As the earthy phosphates only seldom 
occur in large amount in the urine, it is usually not 
considered necessary to separate them by filtration 
before testing for the alkali phosphates. If we have 
previously tested with KOH or (NH 4 ) OH, for the 
earthy phosphates, with a little practice we can easily 
distinguish the others from the turbidity caused by the 
precipitation of the earthy phosphate. If the earthy 
phosphates are present in great amount, we must pre- 
cipitate them with ammonia, filter, and test the filtrate 
with the magnesium mixture. 



82 ANALYSIS OF THE URINE. 

3. Sulphates, 

The sulphates contained in the urine are the neutral 
sulphates of potassium and sodium. 

As the sodium salts predominate in the animal 
organism, so is there in the mine more sulphate of 
sodium (Na 2 S0 4 ) than sulphate of potassium (K 2 S0 4 ). 
The sulphuric acid which a sound man excretes in 
twenty-four hours amounts to 1*5 to 2*5 grms., usually 
2 grms. 

The test for sulphuric acid or the sulphates is made 
quite similarly to that for the phosphates. 

Take 10 c.c. of urine in a beaker and acidify with 
a few drops of HC1 (so that the barium phosphate will 
not precipitate at the same time), and add a third part 
(3-4 c.c.) of the chloride of barium solution. We have 
the reaction — 



Ba Cl 3 + Na* SOJ = 2 NaCl + BaS0 4 



If we had not previously added HC1, then the sodium 
phosphate in the urine, by the addition of BaCl 2 , would 
be precipitated as barium phosphate. 

If we have previously added an excess of HC1 to 
the BaCl 2 solution, it is not necessary to acidify the 
urine before testing. (Chapter IV., No. 7.) The white 
precipitate which is formed by the BaCl 2 solution is the 
sulphate of barium. 

If an opaque milky cloudiness results from this 
reaction, the sulphates are present in normal quantity 



THE URINE. 83 

If the cloudiness is more intense, so that the urine has 
the appearance of cream, the sulphates are increased. 
If, on the contrary, a translucent light cloudiness ensues, 
then the sulphates are diminished. 

A very pretty approximate test has been given by 
J. Vogel. The normal urine should contain in twenty- 
four hours about 2 grms. of H 2 S0 4 . If a patient passes 
2,000 c.c. in twenty-four hours, this should contain 2 
grms., or in 100 c.c. of urine 0-1 grm. H 2 S0 4 . Take 
now 100 c.c. of this urine and add as much BaCl 2 solu- 
tion as is necessary for the precipitation of half the 
sulphuric acid (0*05 grm.) and filter. If the nitrate 
remains clear after the addition of BaCl 2 , there is no 
more H 2 S0 4 present ; the amount of the latter is there- 
fore very much diminished. If a cloudiness ensues 
after adding BaCl 2 to the nitrate, add as much BaCl 2 
as will precipitate 0*05 grm. of the acid and filter 
again. If the filtrate remains clear after a fresh addi- 
tion of BaCl 2 , then the amount is normal, for we have 
taken as much BaCl 2 as would be necessary to precipi- 
tate 0*05 + 0*05 = 0*1 grm. (the normal amount) of sul- 
phuric acid. If, however, a turbidity ensues, there is 
more than the normal amount of H 2 S0 4 present. 

An increase of the sulphates or sulphuric acid is ob- 
served — 

(1.) After an exhibition of sulphuric acid or the 
soluble salts of the same, and from sulphur-containing 
compounds or sulphur. 

(2.) From exclusive flesh diet, for the sulphur of the 
albuminous compounds is oxidized to H 2 S0 4 . 



-4 ANALYSIS OF THE URINE. 

) In acute febrile j see with rich 

urea. The increase of PL S0 4 in this case is referred 
the increased decomposition of the sulphur-contai: 
principles of the body (albuminate- ). The greatest 
increase is observed in meningitis, encephalitis, and 
rheumatism, as well as affections of the muscular system. 

A f t/i tes occurs with an exclusive 

vegetable diet, as well as at the beginning of typhus, 
and besides (in percentage) in all those urines which 
show a low specific gravity. 

Of the inorganic substances, there are prese: 
the urine ammonia (average 0*8 gmi.) and traces of 
iron and silicic acid. According to Duchek, the former 
is increased by advance of febrile processes, and dimin- 
ished by convalescence. 

c. Abnormal Constituents. 

1. Album 

In normal mine albumen should never exist ; but 
in pathological urine, especially when accompanied 
with di >f the kidney, albumen is often present 

iu considerable quantity. 

[In view of the very numerous cases recently re- 
corded in which, without apparent disease, albumen has 
been discovered in the urine, following not only severe 
muscular exertion (long marches of soldiers, fencing, 
boxing, climbing, and other athletic exercises), or 
shower-baths, or even ingestion of food, it seems to us 
that this statement is too positive. Indeed, recent in- 



THE URINE. 85 

vestigations and our own experience incline us to the 
view, so ably advocated by Senator,* that albumen 
always exists in normal urine, but in such exceedingly 
small quantity, and in such extreme dilution, as to ren- 
der its detection by our present methods frequently 
impossible. With the increasing delicacy of our meth- 
ods its detection is the more frequent.] 

After an abundant use of egg-albumen, according to 
CI. Bernard, Becquerel, and others, the same has been 
found in normal urine. Serum -albumen in very small 
quantity (to 0°1 per cent.) may appear even for a year 
in the urine of otherwise healthy men without occasion- 
ing any annoyance. We have observed many such 
cases (" Wiener mecl. Presse," 1870), as has Vogel. If 
this albumen had not been accidentally discovered in 
the urine, the affected persons would never have dis- 
covered it from their general condition. The cause of 
this albuminuria is still somewhat obscure. The urine 
in these cases was strongly concentrated, intensely acid, 
and contained a greater percentage of urea and uric 
acid. In the sediment sometimes nothing, but often 
crystals of oxalate of calcium and uric acid, could be 
discovered. It is probable that this albuminuria, which 
is for the most part periodical and with a very variable 
amount of albumen, is to be explained by the changed 
chemical characteristics of the urine. It is possible, 
besides, that an abnormal innervation of the kidney 
may give rise to this albuminuria. These cases occur 

[* Senator, " Albuminuria in Health and Disease," and Appendices. 
"!New Sydenham Society Publications" for 1884.] 



86 ANALYSIS OF THE URINE. 

so rarely, however, that the appearance of albumen in 
the urine may be regarded as no normal indication. 

Why we find no albumen in normal urine may 
best be explained by Ludwig's mechanical theory of 
the urine secretion. This is based, on the one hand, 
upon the relation of the pressure in the blood-vessels 
to that in the urinary tubules, and on the other, upon 
the osmosis of substances through animal membrane. 

Graham divides all bodies into crystalloids and col- 
loids, calling those bodies crystalloids which penetrate 
animal membranes without difficulty, and easily crystal- 
lize, and those colloids which penetrate with great diffi- 
culty or not at all, and do not crystallize. If we apply 
this classification to albumen, and especially to serum- 
albumen, we find that it is a colloid body, for it neither 
crystallizes nor penetrates animal membrane except 
under great pressure. As the crystalloid substances 
easily penetrate animal membranes and the colloids do 
not, it is to be supposed that the cause lies in the molec- 
ular constitution ; that perhaps the molecule of albu- 
men is greater than that of any soluble salt. This 
theoiy gains probability if we observe the constant 
foam on an albuminous solution, as also the complex 
chemical composition of the same. We find the ex- 
traordinary size of the albumen molecule in the ex- 
pression of its atomicity, ^eH^N^SgOgg. 

According to Lud wig's theory, the secretion in the 
glomeruli is a transudation process, and in the urinary 
tubules a diffusion process. We find that in the kidney 
the blood is always separated from the urine by an ani- 



THE URIXE. 87 

mal membrane. These animal partitions permit the 
crystalloids of the blood (as salts, urea, etc.) easily to 
penetrate ; but the colloids (albumen), under a normal 
blood-pressure, can not pass through, and on this ac- 
count we find no albumen in normal urine. 

If we find albumen in the urine, then the blood- 
pressure in the renal vessels is generally increased (hin- 
dered venous circulation, heart disease, amyloid degen- 
eration of the vessels, etc.), or the animal membrane is 
defective in some place (parenchymatous nephritis and 
Bright' s disease). 

Of albumen, we chiefly find in the urine serum- 
albumen and paraglobuline. If to the urine are added 
other albuminous animal fluids (e. g., blood, pus, exuda- 
tions, etc.), we find the variety of albumen correspond- 
ing to these fluids. Fibrine comes with intense haemor- 
rhage and with croupous affections of the urinary 
apparatus. 

A true fibrin uria — that is, a coagulable urine — 
which occurs on the Isle of France, is seldom observed 
with us. We mentioned this in three cases of villous 
tumors of the bladder (p. 42). We often observe a 
honey-like, sirupy urine, the thick consistence of which 
is not due to fibrine, but to pus dissolved in the alka- 
lies. Such urine becomes thinner on addition of water ; 
and if we treat the same with acetic acid, there falls a 
white precipitate of alkali albuminate. This albumi- 
nate arises from the reaction of carbonate of ammonia 
on the serum -album en of the pus. 

For albumen there are many characteristic reactions, 



ANALYSIS TEE CBIXE. 

but for the urine there ax 

the concentrated nitric i I HNO s ) and the heat testa 

1. For the UNO : - b 1 of urine should be 

taken in a win -glass, and then pi concen- 

trated HXv raining) should be allowed I ilow 

down the side layer I i the 

mine, X w, if albumen is present, a white will 

a. This can on 
founded with the urates which are pre ; itated in a 
: -imilar manner when present in great amount, 
also with the resin o1l copaiva. In the : the 

nratee they are not preci in the zone between 

the fluids, but - vj.ewhat highei and are t sha 

i ne, but eurl upward from the centre, 
having the appearance of as ling smoke. 

K albm 1 much urates are present in a mine 

at tl the nitric ad 1 tion 

layers, i the >ther. The lower la; 

sha: ined above and :ween the colorless 

and the mine, is the albume:;. The up] er h 

lually becoming more intense and not sharply 
fine but as snding is a white cloud, con-> (x 

the A layer of clear urine separates thee 

The layer prod -in of copa 

on the addition of a few drops of alcohol 

I: y the nitric si to nonnal urim 

beerv acid and the urine a brown ring 

irine-coloring matt a, which in a few niin 
comes more voluminous. In febrile proc 88 a, hen the 
urine c much coloring matter, this ring is 



THE URINE. 89 

intensely colored. As albumen when present appears 
in the same zone, this does not form now as a white 
layer, but is more or less tinged with brown. If much 
indican is present, the urine often appears a beautiful 
rose-red or even violet ; from the presence of blood-col- 
oring matters, brown-red ; from undecomposed bile-col- 
oring matters, a beautiful green. If a urine is strongly 
concentrated and we add HlSTOg, a copious crystalline 
precipitate of nitrate of urea falls, which under the mi- 
croscope shows the characteristic colorless rhombic ta- 
bles. From a urine rich in uric acid we often see beau- 
tiful shining light yellow-colored whetstone crystals, 
which can be easily distinguished micro-chemically 
from nitrate of urea, because they are not soluble in 
water. 

If the urine contains much carbonic acid, either be- 
cause it is alkaline and contains much ammonium car- 
bonate, or because it has a neutral or even acid re- 
action and contains much sodium carbonate or free 
carbonic acid (as is the case from use of alkaline and 
carbonated mineral waters), we observe that the fluid 
by addition of HN0 3 becomes sparkling and sometimes 
even effervescent. 

If there is doubt about the presence of albumen, 
then we must employ the heat test. It is always well 
to do both. 

2. The boiling test. — If the urine is acid, we take 
8-10 c.c. and boil in a test tube ; it is safer, however, 
to add previously one or two drops of acetic acid. A 
flocculent cloudiness after boiling indicates albumen. 



90 ANALYSIS OF THE URINE, 

If the urine is but feebly acid, is neutral, or has an 
alkaline reaction, it is possible that a precipitate may 
form upon heating, which is again dissolved by the ad- 
dition of acetic acid. This precipitate is not albumen, 
but consists of calcium carbonate mixed with earthy 
phosphates which were held in solution by carbonic 
acid ; the carbonic acid being driven off by the heating 
allows them to precipitate (Heller's bone dust). What 
may happen with acid urine is much more liable to 
occur with neutral or alkaline ; it is therefore best to 
acidify, to avoid confusion. 

In making the boiling test with alkaline urine, the 
unpracticed may be easily misled as to the presence of 
albumen. The HX0 3 test succeeds here with difficulty 
or not at all, because of the brisk effervescence occa- 
sioned by the separation of the carbonic acid gas from 
the ammonium carbonate. If the urine is not acidified 
and contains a small quantity of albumen, the alkali is 
sufficient to change the albumen to an alkaline albumi- 
nate, which is not coagulated by heat. If acetic acid 
is not carefully added, but on the contrary an excess 
has been used, an acid albuminate may form, which is 
also not coagulated by heat. A small amount of albu- 
men is with difficulty recognized if the urine is turbid 
and remains so after filtration. Alkaline urines are 
always more or less cloudy, and contain for the most 
part no earthy phosphates in solution. Such urine 
must be cleared up before testing for albumen. For 
this purpose it must be boiled with a quarter of its vol- 
ume of KOH solution and filtered. (Chapter IV., No. 



THE URINE. 91 

5.) Should the filtrate not be quite clear, we must 
add one or two drops of the magnesium mixture, warm 
again, and filter. This filtrate always appears clear and 
transparent. If we carefully acidify now with acetic 
acid, we observe a slight cloudiness from albumen, 
though this will show more distinctly if to the fluid, 
after acidifying with acetic acid, we add a few drops 
of a solution of potassium ferrocyanide without warm- 
ing, shake, and permit the sediment to settle for a few 
minutes. We observe now on the bottom of the test- 
tube the white flakes of precipitated albumen. 
It is well to know a few other tests. 

a. Acidify strongly with acetic acid, and add to the 
urine its volume of a cold saturated sodium-sulphate 
solution and boil. 

b. Drop into a perfectly clear urine a cold saturated 
picric acid solution. If a white cloud forms, then is 
albumen present. (Galippe's test.) The cloudiness 
only lasts for a moment. 

Albumen is found in the urine — 

(1.) When the blood-pressure in the glomeruli be- 
comes greater than normal. This occurs in all disturb- 
ances of the circulation, as heart-disease, impeded ve- 
nous circulation, amyloid and atheromatous degenera- 
tion of the blood-vessels, etc. 

(2.) In all those diseases which involve an altera- 
tion of the diffusion membranes of the kidney ; i. e., the 
walls of the tubules with their epithelium, and the 
neighboring fine arteries or their capillaries (parenchy- 
matous nephritis, Bright's disease, etc.). 



92 ANALYSIS OF THE URINE. 

(3.) If blood, pus, or any other albuminous fluid is 
mixed with the urine (false albuminuria). 

(4.) Sometimes with hydremia (imperfect nutrition 
of the capillary walls). 

[(5.) With functional disorders.] 

It is also said (Vogel) that albuminuria may result 
from a peculiar albumen that is formed in the blood, 
which penetrates the intact membranes by quite another 
diffusion process. But such a form of albuminuria we 
have never had an opportunity of observing. 

In true albuminuria it is important to observe the 
amount of urine passed in twenty-four hours, for only 
by an increase or decrease of the contained albumen 
can a better or worse condition of the kidney disease be 
recognized. The most accurate quantitative determina- 
tion of albumen is made by means of the balance, or 
by the employment of a polarization apparatus (Chap- 
ter V.). These methods are too troublesome for the 
practicing physician, but there remains a method by 
which it may be readily discovered whether albumen 
exists in small (under \ per cent.) or in great (1-2 per 
cent.) quantity. With a little experience one can esti- 
mate approximative^ the percentage from the appear- 
ance of the white albumen zone which forms between 
the fluids on the addition of the strong nitric acid. If 
this zone is faint and feebly white, and has no lumpy 
appearance, but is almost transparent and only visible 
as a sharply-defined band on a black background, hav- 
ing the height of but 2-3 mm., we may say that albu- 
men is only present in small amount (less than \ per 



THE URINE. 93 

cent., usually y 1 ^ per cent.). If this zone appears from 
4 to 6 mm. high, snow-white, opaque, and distinctly 
recognizable without a black background, and of a floc- 
culent appearance, then albumen is present in consider- 
able quantity (J- i per cent.). But if on the addition 
of the acid the albumen appears lumpy and flaky, and 
more or less falls to the bottom, and by stirring with a 
glass rod the urine becomes of a creamy consistence, 
then albumen is present in large amount (1-2 per cent, 
and more). 

We can make a similar investigation with the boil- 
ing test. Take a test-tube, fill it a third full of clear, 
filtered urine, and heat it. Should the urine be alka- 
line, it must be acidified with acetic acid. A slight 
turbidity after heating, the urine still being transpar- 
ent, with only a feeble opalescence, indicates a small 
amount of albumen, and only after long standing a 
light flocculent sediment forms. If the urine becomes 
cloudy by heating, and the albumen separates out as 
flakes, and a layer comes down on the bottom the thick- 
ness of a finger, then albumen is present in moderate 
amount. If albumen is precipitated in large lumps, 
and not, as in the other cases, near the surface of the 
fluid, but lower down where the flame surrounds the 
test-tube, and appears to be of a creamy consistence, 
then albumen is present in great amount. If we would 
compare the amount of albumen one day with another, 
we must boil a like quantity of urine in similar test- 
tubes, and compare the mass of the sediment after it has 
well settled. It is more advantageous to employ glass 



94 AXALYSIS OF THE UEIXE. 

tubes of uniform calibre, stopped at the lower end with 
corks covered with waxed paper, presenting a level 
surface, measuring the height of the precipitate at the 
expiration of twenty-four hours. 

These are only a few suggestions for the practicing 
physician, but he must be very familiar with the char- 
acteristic reactions in order to draw satisfactory conclu- 
sions from the latter tests. 

What has been said above applies to those cases in 
which the albumen is serum-albumen. 

[Acid albumen or syntonin, and alkali albumen or 
casein, may occur in the urine when it is strongly acid 
or alkaline. Neither of these is excreted as such, but 
they are produced by the action of acid or alkali in the 
urine upon ordinary albumen (Ralfe). They are non- 
coagulable by heat, and hence may be overlooked ; but 
they may be reconverted into ordinary albumen by the 
action of alkali or acid respectively.] 

Frequently other modifications of albumen occur, 
of which the most important is globuline (perhaps 
myosin e). 

In order to prove the presence of globuline in the 
urine, it must be diluted until it has a specific gravity 
of 1'002 ; then add very carefully diluted acetic acid 
(for globuline is soluble in concentrated acid) ; usually 
a cloudy turbidity results. In order to precipitate all 
the globuline, we must pass a stream of carbonic acid 
gas slowly through the solution for from one to two 
hours. After standing some time, the globuline falls 
as a white powder. After pouring off the supernatant 



THE URINE. 95 

fluid, it can be tested for albumen by the above meth- 
ods. If the sediment consists of globuline, it will dis- 
solve in a few drops of a concentrated sodium-chloride 
solution. The test is best made in a wine-glass or de- 
canting-glass. (For further consideration of myosine 
and paraglobuline, see K. B. Hofinann, 1. a, 73 and 
323.) 

Globuline is observed in great quantity in bladder 
catarrh, acute nephritis, and especially in amyloid-de- 
generated, or waxy kidney ; while from chronic Bright' s 
disease it may be very small in quantity or entirely 
wanting. [It has also been found with albuminuria 
apparently dependent upon disturbance of the digest- 
ive organs.] 

Peptone is contained in every albuminous urine. 
In those cases where the temperature is very high, it 
may occur without other albumen in the urine. 

[Peptone may occur in normal as well as in patho- 
logical urine, and its clinical significance has not been 
definitely ascertained. Yon Jaksch diagnosticated the 
rupture of the sac and suppuration in a case of ovarian 
tumor from its presence ; but Grocco denies that it can 
be used as a means of diagnosis between simple and 
purulent exudation. It occurs in two groups of cases — 
general and local. In the former (including scurvy, 
typhus, diphtheria, tertiary syphilis, small-pox, cerebro- 
spinal meningitis, phosphorus poisoning, etc.) it seems 
to be connected with a disorganization en masse of the 
leucocytes; in the latter (including pleurisy, croupous 
pneumonia, chronic bronchial catarrh, acute Mamma- 



ANALYSIS OF THE URJNR 

rheumatism ) it is associated with the resorption 
of an exudation rich in cellular element-. Its amount 
depends upon the character of the exudation (abun- 
dance, richness in globules, more or less rapid disorgan- 
ization, and resorption), and the extent of surface and 
permeability of the walls containing the exudation. In- 
deed, it may appear in the urine (with or with 
scrum-albumen) whenever, from imperfect digestion or 
other cause, it occurs in the blood. It also appears 
(Ralfe) from excessive formation of young cells along 
the genito-urinary tract. Decomposing albumen in the 
urine itself is another source. Inasmuch as it may be 
chemically mistaken for albumen, it is well to know 
^jine of its reactions. It is not coagulated by heat or 
nitric acid, nor is it precipitated by acetic acid and fer- 
rocyanide of potassium. It is, however, precipitated 
by alcohol, tannic acid, potassio-mercuric iodide, rneta- 
phosphoric and picric acids, acidulated sodium chloride 
solution, and phospho-tungstic acid (or sodium tung- 
and it gives a rosy-red color with alkaline solu- 
tions of cupric sulphate. Randolph's test (Philadelphia 
- Medical News," May 10, 1884) has not proved satis- 
factory in our hands. Probably the best method for 
detectin. that of Hofrneisteiy'- which is, however. 

complicated for ordinary clinical use. For a recent 
of the - I -•■. " De la Peptonurie," 

par Ch. E. Noury, Pari-. 1884. 

Ilemi-albumose, or pro-peptone, a product of gastric 
and pancreatic digestion, and intermediate between al- 

* "2ur Lehre von Pepton,' 1 " Zeit. fur phys. Chcniie," Bd. IV., p. 256. 



THE URINE. 97 

bumen and peptone, has been detected in the urine sev- 
eral times of late, and deserves notice. It was first 
found as a constituent of urine by Bence Jones in a 
case of osteo-malacia, and in another case of the same 
disease by Kuhne. Virchow discovered it in the me- 
dulla of osteo-malacic bones, and Fleischer in the nor- 
mal bone medulla. Stokvis found it in the urine of a 
dog, into whose rectum he had previously injected it ; 
and Lassar found it in the urine of rabbits after having 
rubbed petroleum into their skin. Senator found it in 
seven cases, one each of tertiary syphilis, hemiplegia 
double pneumonia, diphtheria, carcinoma, single pneu 
monia, and muscular atrophy. In the latter case, how 
ever, there had been diphtheria four years previously 
with dysentery and hemorrhagic nephritis as sequelae 
and later neuritis of the left brachial plexus, with con 
sequent paresis and atrophy of the arm. Pro-peptone 
has also been found in the blood during digestion, and 
also in pus. It is not coagulated by heat nor the addi- 
tion of nitric acid to its hot solution ; it is precipitated, 
however, by nitric acid (in the cold) and by acetic acid, 
with potassium ferro cyanide, or a strong solution of so- 
dium chloride. It also gives the biuret reaction. It 
may be isolated (Tyson) from urine by acidulating 
with acetic acid, adding one sixth volume of concen- 
trated sodium chloride solution, boiling and filtering. 
If, on cooling, the filtrate becomes turbid, with or with- 
out the further addition of sodium chloride, and the 
turbidity disappear on heating to reappear on cooling, 

pro-peptone is present. If desired, the second precipi- 

7 



98 ANALYSIS OF THE URINE. 

tate may be filtered off, dissolved in a little water, 
and reprecipitated with acetic acid and potassium ferro- 
cyanide. 

Owing to the importance of mucin as a source of 
error in testing for albumen, especially with the later 
and more delicate tests, it is appropriate to say a few 
words regarding it in this place (for further particulars 
see under " Sediment," p. 165). Mucin is a substance 
closely allied to the albuminoids, but contains no 
sulphur. It is the active constituent of mucus, and is 
contained in greater or less quantity in all urines. In 
normal urines it is present in very small quantity, and 
in a state of suspension or false solution. Its appear- 
ance in abnormal quantity, without albumen, has little 
clinical significance, except as indicating a slight in- 
flammation of some part of the genito-urinary tract. 
It is not coagulated by heat, and is soluble in the alka- 
lies and strong mineral acids, and in water (false solu- 
tion). It is precipitated by alcohol, all organic acids 
(including picric, Oliver), and dilute mineral acids ; an 
excess of the latter will, however, redissolve the pre- 
cipitate. In order to get rid of this disturbing ele- 
ment, when using the more delicate tests for albumen, 
it is best to add acetic acid (in the proportion of two 
drops to 10 c.c. of urine), as long as there is resulting 
turbidity, set the test-tube aside for an hour or so, 
and filter through double filter-paper before adding 
the reagent. 

Pepsin, trypsin, and a diastatic ferment have been 
found in normal as well as pathological urine. 



THE UEIXE. 99 

The following reagents, enumerated in the order 
of their delicacy, have received extended professional 
attention since the first edition of this work. 

' Potassio-mer curie iodide was first introduced by M. 
Ch. Tanret, of Troyes, in 1872, and is an exceedingly 
delicate reagent for detecting albumen. The basis of 
its reaction is the precipitation of albumen in an acid so- 
lution by the double iodide of mercury and potassium. 
The test liquid consists of ^potassium iodide, 3*22 grms. ; 
mercuric chloride, 1*35 grm. ; distilled water to 100 c.c; 
and, as a confirmatory solution, a 1 per cent, solution 
of mercuric chloride. 

The test may be used qualitatively or quantita- 
tively. 

For qualitative testing add one or two drops of 
acetic acid to 10 c.c. of urine under stirring (if a de- 
cided turbidity result, filter), and then add the reagent 
drop by drop. If albumen be present, a white, opaque, 
fiocculent precipitate will form, and will not be dis- 
solved in excess of reagent. 

The quantitative test is veiy simple, and is as fol- 
lows : To 10 c.c. of urine add two drops of acetic acid 
as before, and then add the reagent drop by drop (from 
a pipette which will give a drop of 0*05 grm.), stirring 
carefully each time until the precipitate is no longer 
resolved in the albumen in excess; then, after each 
drop of the reagent, put a drop of the mixture on a 
porcelain dish, add a small drop of the confirmatory 

* This is the formula given by Stephen (London "Lancet." October 14, 
1882, p. 614), and is the one nsed by ns. 



100 ANALYSIS OF THE URINE. 

solution, and watch whether a yellowish-red color ap- 
pears. As soon as it does, all the albumen is precipi- 
tated and the reaction is finished. 

As the precipitating solution is so constituted that 
one drop from the five-centigramme pipette will pre- 
cipitate five milligrammes of albumen, and it takes 
three drops to give the color reaction with the con- 
firmatory solution, the number of drops used, less three, 
multiplied by five, will give the number of milligrammes 
in 10 c.g. of urine; or, more simply, each drop, after 
three have been subtracted, will represent a half 
gramme of albumen in a litre of urine. From this, of 
course, the twenty-four hour amount can be readily 
computed. 

If this test be improperly performed, mucin, urates, 
urea, peptones, and vegetable alkaloids will be precipi- 
tated, as well as albumen. The two former may be 
eliminated as before mentioned. If sufficient acetic 
acid has been added, urea is not precipitated. Pep- 
tones and the vegetable alkaloids are dissolved by heat. 
Of the vegetable alkaloids, the only ones likely to be 
present in disturbing quantity are those of cinchona 
bark and opium. In view of these facts, however, no 
known quantitative test founded on the precipitability 
of albumen by this reagent can be chemically exact as 
applied to the urine. 

Picric acid mainly owes its present popularity to 
Dr. George Johnson, of London,* who was unaware, 

* lie has contributed a series of papers to the London a Lancet" (be- 
ginning in 1882) regarding its use in urinary analysis. 



THE URINE. 101 

when he published his first investigations, that Galippe 
had preceded him in its discovery as a test for albu- 
men. This reagent is almost as delicate as potassio- 
mercuric iodide, and much more so than nitric acid. It 
is also non-corrosive, but will stain clothes and fingers, 
as microscopists are aware. It may be used in powder, 
or, better, in saturated solution (about one part acid to 
fifty parts distilled water). Some authorities (as Dr. 
Oliver) advise the addition of citric acid to the test 
solution; but, in our opinion, it is better to add the 
citric, or acetic, acid to the suspected fluid before add- 
ing the reagent, so that their effects can be differ- 
entiated. Dr. Johnson himself thinks the addition of 
another acid unnecessary. The best method of using 
this test is by overlaying the suspected fluid with the 
test solution (having previously acidulated, as in the 
foregoing test), which the specific gravity (1003) of 
the latter renders possible in most cases. This is best 
accomplished by adding gently from a pipette nearly an 
equal volume of test fluid to 10 c.c. of urine contained 
in a test tube which is slightly inclined. If albumen 
be present, a white flocculent precipitate will take 
place just above the zone of contact, contrasting dis- 
tinctly with the bright yellow of the picric acid solu- 
tion. This precipitate is soluble in excess of albu- 
minous urine, but not of reagent. Mixture, not mere 
contact at the point of junction, of the two fluids is 
necessary to produce this reaction. 

This reagent is open to the same objections as the 
preceding, and has almost the same advantages. It pre- 



102 ANALYSIS OF THE URINE. 

cipitates mucin (Dr. Johnson to the contrary notwith- 
standing), urates (when present in excess), peptones, 
and vegetable alkaloids, as well as albumen. The two 
first may be eliminated as in the preceding test, and all 
of them dissolve on heating except mucin and albumen, 
so that all sources of error can easily be removed. 

Sodium tungstate was brought before the profession 
by Dr. George Oliver,* and he recommends for the 
test solution equal parts of saturated solutions of so- 
dium tungstate (one to four) and citric acid (ten to 
six). Owing to its specific gravity (1214) it is best 
used as nitric acid in Heller's method. It is very deli- 
cate, being about as sensitive as picric acid (according 
to Oliver, it will detect one part albumen in 20,000 
water), and precipitates the same substances, with the 
exception of alkaloids. Heat also has the same effect 
on precipitates caused by it. 

Potassium ferrocyanide is less delicate than the 
preceding three reagents, but more so than nitric acid. 
It is used in saturated solution, and requires previous 
acidulation of the urine. It does not precipitate mu- 
cin, peptone, or the alkaloids, but does throw down the 
urates. 

Metaphosphorio acid, introduced by Hindenlang,f 
and the brine test of Roberts, have had their advocates ; 
but there are serious objections to both. The first is a 
very sensitive reagent, but precipitates proteids and is 
not stable, for, on standing a short time, it becomes con- 

* London "Lancet," Vol. I., 1883, p. 139 et seq. 
t " Berlin, kl'in. Wochenschrift," 1881, No. 15. 



TEE URINE. 103 

verted into orthophosphoric acid, which does not pre- 
cipitate albumen. The brine test (saturated solution 
of common salt acidulated with one per cent, strong 
HC1) is not as delicate as either picric acid, sodium 
tungstate, or potassio-mercuric iodide, and precipitates 
proteids besides. On this account its author has dis- 
carded it in the last edition of his work. 

While some authorities, noticeably Dr. Roberts, 
consider these new reagents of little clinical value, 
and rely simply upon nitric acid and heat for the de- 
tection of albumen, we can not agree with them. The 
precipitation of so many substances, usually of differ- 
ent clinical significance from that of albumen, is often 
misleading if we rely on any one test ; yet a combina- 
tion of two of them, as the potassium ferrocyanide 
and picric acid, or potassio-mercuric iodide, may give 
us valuable information not only in regard to albu- 
men, but also in regard to other proteids. Besides 
which, with proper manipulation of any one of these 
tests with heat, we can eliminate sources of error, and 
even the nitric acid test (a less sensitive one) ought 
always to be supplemented by boiling, and sometimes 
by alcohol in addition. The negative value of the 
most delicate reagents is unquestionable, and any albu- 
men undetected by them is certainly of no clinical sig- 
nificance. It is true that we have not yet worked up 
to the full pathological significance of the trace of albu- 
men missed by nitric acid and heat and detected by 
other tests, but it may not be long before we do so, and 
even now we should be put on our guard against a more 



104 ANALYSIS OF THE URINE. 

serious albuminuria. With our present knowledge we 
think it best to begin testing a suspected urine with one 
of the most delicate tests, and, if albumen or a proteid 
be indicated, apply heat and nitric acid certainly, and, 
better, some of the other proteid tests, of course sup- 
plementing all by the microscope before forming a 
diagnosis. 

Dr. Oliver* has ingeniously contrived a series of 
" test papers " suitable for bedside testing, but not, in 
our opinion, as satisfactory as the solutions. They are 
arranged for sugar and albumen testing (the latter 
based on the recent delicate tests), and are for sale in 
London and in this country. f] 

2. Suga7\ 

The urine - sugar, C 6 H 12 6 -|- H 2 (identical with 
grape-sugar), is, according to Briicke, a constant con- 
stituent of normal urine. It is present in such exceed- 
ingly minute quantity, however, that when we use 
Trommer's test we do not observe the least precipitate 
of yellow cuprous hydrate. We observe that the mix- 
ture simply changes color. In pathological urine, espe- 
cially in diabetes mellitus, we find so great an amount 
of sugar that the urine possesses a sweet taste ; and if 
a piece of cloth is saturated with it, after the evapora- 
tion of the urine the cloth is as if smeared with honey. 

[* See London " Lancet' 1 for 1883, and " Bedside Urine-Testing," Lon- 
don, 1885. 

t Parke, Davis & Co., New York and Chicago, prepare a very conven- 
ient case containing them, with directions for their use.] 



THE URINE. 105 

The urine-sugar crystallizes in agglomerated masses, 
which resemble cauliflower in form. 

Of the various tests for sugar, the following are 
generally employed : 

1. Heller's or Moore's Test. — Pour into a test-tube 
two volumes of urine and one volume of KOH or 
NaOH, and heat to boiling. The earthy phosphates 
fall, and if present in great amount must be filtered 
off. As soon as the fluid becomes hot, a lemon-yellow, 
yellowish-brown, or blackish-brown color appears, ac- 
cording to. the amount of sugar present. If we now 
treat this with a few drops of nitric acid, the dark color 
vanishes, and it gives off the smell of molasses. If al- 
bumen is present in great amount, it should be pre- 
viously separated by boiling and filtering. If the urine 
has a dark color, which is seldom the case in diabetes, 
we must render it colorless by acetate of lead (by this 
means a slight amount of sugar falls), or by filtration 
through animal charcoal. This filter must be washed 
with water, for it contains much sugar. 

If the urine has a dark color from the addition of 
KOH in the cold, it is generally due to the biliary col- 
oring matter. This change of color takes place if the 
biliary coloring matters have already decomposed, i. e., 
if the urine does not give Gmelin's or Heller's test for 
the biliary matters. In this case the change of color, 
especially if by the addition of sulphuric acid a very 
dark color is produced, is a good proof of the presence 
of biliary coloring matters. 

According to Bodecker, if a mine which has been 



MM IXKStta ¥ THE CBIXE. 

treated witi -iuni liydra: e ( K OH and allowed to 

stand in the air gradually colo a above 

downward by absorption of _. it contain- 
culiar substance wliicli lie calls alkapton. This 

iuce tlie copper salt, but not the -alt 

ly this t . is pyrocateckine. 

T>:\ "vT. G\ Smith* met with a case in which the 
urine (that of an apparent- healthy child, three y 
old, and not taking medicin-r gave the 

:ions of Bode rfkapt n, L -.. strong ali 

darkened the urine without the application of heat, and 
the discoloration p: ; se led from the surface down | ni- 
dation ting ~ith the alkali); it partially re- 
duced the copper test, and was unfermentable by yeast. 
This substance also quickly reduced silver nitrate and 
had a slight reaction with the Lowe bismuth test for 
sugar. Feme chloride produced a distiL ■:: green color, 
turned to reddish-brown upon the addition of an alkali 
The specimen contained no bile or albumen. From 
these and other reactions mentioned in Dr. Smith's arti- 
cle, he concluded that the sal stance in question was 
protocatechuic acid, a conclusion confirmed by Prof! 
Hartley's optical examination. It would seem, there- 
fore, that M alkapt':«iL " is to be regarded as a general 
term. 

ML Vetlesenf reports that, after the internal ad- 
mit, d of turpentine, there appears in the urine, 
in rather large quantity, a substance fermentable slowly 

[* Dublin M Journal of Medical Sda 

t Abstract in " Medical Times aDd Gu '6-L] 



THE URINE. 107 

by yeast, without dextro-rotatory power, which will re- 
duce an alkaline solution of bismuth oxide on boiling, 
and also cupric oxide, and a small amount of hydro- 
chloric acid will destroy it at a low temperature.] 

Mulder's test gives a beautiful color reaction. If a 
colorless saccharine urine is heated with a solution of 
indigo-carmine, which has previously been made alka- 
line by sodium carbonate, the blue mixture becomes 
first green, then purple-red, and finally yellow. If we 
shake the heated mixture in the air it takes up oxygen, 
and the color again passes back to blue. If but a 
small amount of sugar is present, the indigo-carmine so- 
lution only becomes a pale blue. 

[This test has been adopted by Dr. Oliver in his 
test paper series, and he claims for it sensitiveness 
equal to that of the picric acid or Fehling's test, and 
less liability to sources of error. He also claims ap- 
proximate accuracy for his method as a quantitative 
test. We have had no opportunity of experimenting 
with the indigo-carmine papers prepared in London, 
but those of Parke, Davis & Co. have not been satis- 
factory in our hands ; and, in our opinion, quantitative 
results obtained by the average practitioner from shades 
of color as delicate as those produced in this test are, 
to say the least, open to question. One wishing full 
details of this test will find them in the works of Drs. 
Oliver * and Tyson.f ] 

2. Trommels Test — Treat as before two volumes 

[* " Bedside Urinary Testing," third edition, 1885. 
t " Practical Examination of Urine," fifth edition.] 



106 AXALTSIS OF THE URIXE. 

of urine with one volume of the KOH or NaOH solu- 
tion (1 part in 3) ; add now drop by drop a solution 
of cupric sulphate (1 part to 10), shaking after each 
addition until the mixture shows a clear, beautiful 
azure-blue. Then heat over a spirit-lamp. If sugar is 
present, a reduction of the cupric oxide immediately 
takes place, and in the following order : First appears 
a yellow cuprous hydroxide, which soon loses its water 
and becomes the red cuprous oxide. If the urine con- 
tains albumen in large quantity, it must first be sepa- 
rated by coagulation. If we do not remove the albu- 
men, it has a marked influence on the reaction, so that 
the mixture of urine, KOH and CuS0 4 , does not be- 
come blue, but of a violet color. If neither sugar nor 
albumen is present, we obtain neither an azure-blue nor 
a violet-colored^ solution, but a turbid grayish-green 
fluid, and by application of heat there is naturally no 
reduction of the cupric salt. 

It is better to employ a solution of sodium-potassium 
tartrate (Rochelle salt) in sodium hydrate (NaOH). 
If we add NaOH to the cupric sulphate solution, cu- 
pric hydrate (Cu[OH] 2 ) falls. If grape sugar is pres- 
ent, a corresponding amount to this will be held in 
solution. If we have added too much cupric sulpL 
there is an excess of the precipitated Cu(OH) 2 in the 
solution, and the same must be filtered off, because it 
would otherwise change to the black oxide of copper 
( CuO), and thereby interfere with the reaction. 

By the employment of the sodium and potassium 
tartrate solution we preserve a clear fluid. 



_a.-v.» TEE URINE. 109 

A large amount of creatine, peptone, etc., may pre- 
vent the reduction to cuprous oxide. 

[Roberts's test is practically the same as this, and 
is a modification of Fehling's test used qualitatively. 
He proceeds as follows : " Fill a test-tube to the depth 
of three quarters of an inch with the copper solution ; * 
heat until it begins to boil, and then add a drop or so 
of the suspected urine. If it be ordinary diabetic urine, 
the mixture, after an interval of a few seconds, will 
turn suddenly an intense opaque-yellow color, and in a 
short time an abundant yellow or red sediment falls 
to the bottom. If, however, the quantity of sugar pres- 
ent be small, the suspected urine is added more freely, 
but not beyond a volume equal to that of the test em- 
ployed. In this latter case the suboxide is always 
precipitated yellow, f never red. % The method of per- 
forming the test should be as follows: The copper 
solution having been heated to ebullition, and some- 
thing less than an equal bulk of the suspected urine 
having been added, the mixture is again raised to the 
boiling point. It then changes to an intense opaque 
yellowish-green, and slowly a bright yellow deposit 
precipitates. If the urine contains less than a one half 
grain percentage of sugar, the precipitation does not 
take place immediately, but occurs as the liquid cools 

[* Op. cit., pp. 208-212. 

t Fehling's fluid, see "Quantitative Determination," p. 216. 

| 0. Giacomo ("Oliem. Oentralblatt," 1884, p. 185) finds that creatinine 
will cause the yellow discoloration sometimes seen in testing with Fehling's 
fluid, obscuring the presence of a trace of sugar, and necessitating the pres- 
ence of more copper than would be reduced by the sugar alone.] 



110 ANALYSIS OF THE URINE. 

in five, ten, or twenty minutes, and the manner of the 
change is peculiar. First, the mixture loses its trans- 
parency, and passes from a clear olive-green to a light 
greenish opacity, looking as if several drops of milk 
had fallen into the tube. This green milky appearance 
is quite characteristic of sugar. By this proceeding, 
one tenth of a grain per fluidounce, or less than one 
fortieth of a grain per cent., can with certainty "be de- 
tected, and any quantity below this has no pathologi- 
cal signification, and is a matter of only physiological 
interest." 

He especially cautions against prolonged boiling in 
such cases, as it, and only it, causes the mixture to as- 
sume " a muddy, dirty fawn appearance," with reddish 
deposit, although no sugar be present. The reddish 
deposit he considers due to the precipitated phos- 
phates colored red by some suboxide, "reduced, per- 
haps, through the instrumentality of uric acid." He 
claims, however, that if his method be properly used, 
uric acid and the urates will not be a source of error.] 

3. Bdttger*s Test. — Treat as above two volumes of 
urine with one volume of KOH, and add as much as 
can be taken up on the point of a penknife of mag- 
istery of bismuth (a mixture of basic bismuth nitrate, 
BiO.NOg -J- H 2 0, and some bismuth nitrate, Bi(N0 3 ) 3 
-f- 5H 2 0), and heat for a short time over a flame. 
Sugar reduces the bismuth salts, so that black suboxide 
of bismuth (Bi 2 2 ) is formed. If only a little sugar is 
present, the white bismuth powder is colored light 
gray, because simply a part is reduced. If but a trace 






THE URINE. Ill 

of sugar be present, then an excess of the bismuth 
nitrate may conceal the reaction. 

If albumen is present, this must first be separated, 
for by the decomposition of the albumen a black sul- 
phide of bismuth is formed, which may be easily mis- 
taken for bismuth suboxide. In order to ascertain to 
what the color is due, we take a sample of the urine 
made alkaline, and add to it a few drops of lead ace- 
tate, and boil. A black precipitate indicates the pres- 
ence of a sulphur compound in the urine. 

Briicke recommends for the separation of disturbing 
elements Frohn's reagent.* Take equal quantities of 
water and urine in two test-tubes ; to the first add HC1 
until a drop of the reagent no longer produces cloudi- 
ness. In this way we ascertain approximately how 
much HC1 must be added to the urine. After acidifica- 
tion we treat the urine with the reagent and filter (the 
filtrate should then not become cloudy by the addition 
of HC1 or the reagent). Add now an excess of NaOH. 
Should the precipitate of bismuth hydrate be too co- 
pious, a little should be removed by decantation ; then 
we heat a long time, as with Bottger's test. 

Maschke gives the following modification : Treat 
the urine with one third its volume of tungstate solu- 
tion.f If proteine substances are at hand, there arises 

* Frohn's reagent (iodide of bismuth and potassium): 1*5 grm. of un- 
washed freshly precipitated basic bismuth nitrate is mixed with 20 grms. of 
water and heated to boiling; then 7 grms. of potassium iodide, and finally 
20 drops of HC1 are added. The resulting fluid is orange-red. 

t Crystallized tungstate of sodium, 30 parts ; acetic acid (30 per cent.), 
75 parts ; water, 120 parts. 



112 ANALYSIS OF THE URINE. 

a precipitate. After the settling of the same, add 
a few drops more of the reagent to see if all the 
proteids have come down. To the filtrate add half 
the volume of concentrated NaOH and a small amount 
(as much as half a pepper-grain) of basic bismuth 
nitrate, and shake well. If this is not colored brown 
or black, we must boil for some time and observe 
after cooling whether a black precipitate has formed. 
If the precipitate of bismuth is already black be- 
fore the boiling point is reached, we may decide on 
the presence of diabetic sugar ; a slight browning, 
or later becoming black, shows only the normal 
amount of sugar present. If the bismuth oxide be- 
comes brown before warming, there is a sulphide in 
solution. We must in this case take a new sample 
of urine, weakly acidify with acetic acid, shake up 
well with some bismuth nitrate, and treat the filtrate 
as above directed. 

[In this connection picric acid deserves mention as 
a delicate reagent for the detection of glucose. The 
basis of its use as a test is the fact that when solutions 
of grape sugar and picric acid are boiled together in 
the presence of caustic potash, the yellow picric is re- 
duced to the deep red picramic acid. This was dis- 
covered by C. D. Braun some twenty years ag . but 
was not much utilized until Dr. George Johnson, of 
London,* having accidentally stumbled upon the same 
fact, strongly advocated its application to the examina- 

[* British "Medical Journal."" March 17, 1883, and series of communica- 
tions to the "Lancet," beginning November 18, 1882.] 




THE URINE. 113 

tion of diabetic urine. The test is both qualitative 
and quantitative, and for its performance by Johnson's 
method are necessary : 

1. A cold saturated solution of picric acid. 

2. Liquor potasssB (specific gravity, 1058). 

3. A standard color solution. 
The last is prepared as follows : 
Take a fiuidrachm of a solution of grape sugar in 

the proportion of a grain to the fluidounce (of distilled 
water), mix it with half a fiuidrachm of the liquor 
potassse and ten minims of the saturated picric-acid 
solution, and make up the mixture to four drachms 
with distilled water. Heat this mixture to the boiling 
point, and continue boiling sixty seconds by the watch, 
so as to insure complete reaction between the sugar and 
the picric acid. During the process of boiling, the color 
of the liquid is changed to a beautiful claret-red. The 
liquid is then cooled by careful immersion of the test- 
tube in water, and it having been ascertained that 
there are four fiuidrachms of the mixture, or, if there 
are not, enough distilled water to make up the four 
drachms having been added, the color of the mixture is 
that which results from the decomposition of the picric 
acid by one eighth of a grain of sugar (i. e., sugar 
in the proportion of a grain to the ounce), and is a 
convenient standard for comparison in volumetric 
analysis. 

The color thus obtained is not, however, permanent. 
As a permanent solution of exactly the same shade, 
Johnson recommends : 



114 ANALYSIS OF TEE URINE. 

Liq. ferri perclilor. fort. (B. P.) . f 3 j, 

Liq. amnion, acetat f3iv, 

Acid. acet. glacial f3iv, 

Aq. destillat ad fgijss. M. 

It is a good precaution, before nsing this, to com- 
pare it with some freshly prepared glucose standard 
solution. To perform the test : Take one drachm of the 
suspected urine, half a drachm of the liquor pocassse, ten 
minims of the picric-acid solution, and enough distilled 
water to make four drachms ; raise the temperature of 
the mixture to the boiling point, and continue boiling 
for sixty seconds. If the prolonged boiling has dimin- 
ished the volume of the mixture, bring it to four 
drachms again by the addition of distilled water, and 
compare its color with that of the standard solution. 
It is hardly necessary to state that in this comparison 
vessels of the same shape and size should be used, and 
they should be viewed by transmitted light. 

If the color of the mixture is darker than that of 
the solution, sugar in abnormal quantity is present. 
To determine the exact amount, distilled water should 
be added until the mixture is of precisely the same 
shade as the standard solution. The amount of water 
added should be noted, because the number of volumes 
of water added, plus one (the volume of the mixture), 
give the number of grains of sugar per ounce in the 
urine. For example, if to one drachm of the mixture 
it has been necessary to add two and a half volumes of 
water, 1 — |— 2^ = 3J is the number of grains per ounce. 



TEE URINE. 115 

Inasmuch as ten minims of the picric- acid solution 
only a little more than suffice for the reaction of one 
eighth grain of sugar, a larger proportion of sugar than 
one grain to the ounce would require for its reducing 
action more than ten minims of the picric-acid solution, 
and, in order to determine whether or not sugar is pres- 
ent in such proportion, repeated trials with twenty, 
thirty, forty or more minims of the picric-acid solution 
must be made until the last two trials show the same 
shade of color. If sugar is present in greater amount 
than six grains to the ounce, before making the final 
analysis the urine should be diluted with one or more 
volumes of distilled water, and the resulting mixture 
tested as above. An excess of picric acid will not 
materially affect the test, but the same amount of 
liquor potassse must always be used. 

If the first trial with ten minims shows a lighter 
color than the standard, sugar in less quantity than 
one grain to the ounce is present, which is of slight 
clinical importance. In case it be desired to find the 
exact amount, the standard solution should be diluted 
with an equal volume of distilled water (making the 
color that given by 0*5 gr. sugar to the ounce), and the 
test proceeded with as before. 

From an examination of several hundred s£>eciruens 
of apparently normal urine, Johnson has found that 
there exists in normal urine a substance (or substances) 
which is not decomposed by prolonged boiling, is un- 
fermentable by yeast, and which equally with glucose 
reduces picric acid and cupric oxide. He regards this 



116 >F THE URIXE. 

- saccharoid, 71 and finds it present in the pro- 
portion of 0*5 i 7 gr. per onnce (average 0*6 gr.) in all 
normal urines. This " sa icbai ' substance has been 
proved to inine. The mere boiling together of 

solution of caustic potash will cause 
an orar_ ration (due to the formation of p 

sium picrate). This need not, however, be a source of 
r ; but the presence of alkali sulphides in the urine 
will reduce the picric acid, although Johnson claims 
that the presence of albumen does- not affect the ft 
Oliver states :bat inosite, creatine, and creatinine will 
reduce the acid ; these and other reducing agents some- 
times found in urine are only likely to cause error in 
of very slight glycosuria. The simplicity of the 
method, and the use of the acid as a test for albumen, 
commend its use to the busy practitioner for approxi- 
mative testing in J: ; of glycosuria. We can 
m examination of diabetic urines and artificial solu- 
tions of glucose in water and urine) confirm Dr. John- 
3 statement that its quantitative results are almost 
identical with those by Fehling's test when glucose 
sent in larger quantity than one grain to the 
ounce.] 

Heller's te he simplest and best, and has be- 

at one can form an approximative 
rmination in regard to the amount of sugar present 
from the intensity of the color. In the second rank 
- "lie bismuth test, for if the urine is free from 
albumen there is no other sent which can 

ie uth. As to Trommer- he 



THE URINE. 117 

recommended because, besides sugar, there are in urine 
other bodies which if present in quantity may reduce 
the copper salt. Such are especially uric acid, hippuric 
acid, and the urates. There are many known cases, as 
in febrile processes, in which large quantities of urates 
are present in the urine, where sugar might erroneously 
be supposed to exist, if we relied simply on the yellow 
color of the mixture, without the reduction of the oxide 
having been observed. The most reliable tests for all 
cases are the fermentation and the polarization tests, 
but these are generally inconvenient for the practicing 
physician. 

[Dr. Roberts has devised a method by which the 
fermentation test can be made very useful to practi- 
tioners, provided sugar be present in more than 0*5 per 
cent., or 2 J gr. to the ounce. He has found by re- 
peated experiments (and his results have been practi- 
cally confirmed) that each degree difference (measured 
on the urinometer) of specific gravity between fer- 
mented and unfermented samples of the same saccha- 
rine urine at the ordinary temperature (59°-77° Fahr., 
15°-25° C.) represents one grain of sugar to the fluid- 
ounce ; or, multiplied by the co-efficient 0*23, will give 
the percentage of sugar present. The test is best made 
by taking two samples of the same urine (say 100 c.c. 
each), and to one in a bottle with a nicked cork (to 
allow the generated carbonic-acid gas to escape) add a 
lump of fresh German yeast (about the size of a small 
walnut); put the other in a tightly-stoppered bottle, 
and place the two bottles side by side in a warm place. 



After twenty-four horns take the specific gr avi ty of the 
two specimens (at die ordinary temperature), and the 

lirrrr-L- ' -:~ r-i ::rL -ill :r]:- — :_: :l_r i-i-'-.er :: 
grains of sugar per fimdounee as above mentioned.]] 

- . . i- :-----. . . :"_r : ._- : 
, : r.iri:. : _ i~ /iiTc in: ■;:-;-:.: :; 1:~ ;~ 1;— ii'i:i :.s 
: ::•:" ill 1:~ mil. 1- ri;:-:- 1 in :~ 7:7-::':; 1 :~j>. 
TL-r :_:-: i.;;::.:.:-r . :^:;:^.::"-r iir :!.:•::•? iir -: liri :: 
. :r: T T 17 :;:-_: r_ i::::rzi7>t :;i:1-i-;;l rr ;n 
"1- -j.-::i: ^r^.— —. Tlir Lu;Lt: :1t -":-r.:z: ^: ; : ~1~ 
the more sugar should he present. This is true for a 
~__- i- nip.: ?.-.'.- t.:i. . 1: 1:: ::: -::!_ :. : • .:_: ;"::_! 
r:: ..:-;- :ir *::!:_-. B-r'_ :-: -7 : ir- 1:^ -'_ : ~~ :"_ .-,: :'_> 
method is not always to be relied upon, even for an 

Tl-r — : ;:i 1 i_r:L: 1 i~ :ln: :: V-.^ei. — 1::1 ::i-» 
:i k-rziiiii-. :::^:irn::r :: l-r=s :i:ri- :•:! :::■:- 
duced by the KOH test, the amount of sugar present. 
Tiii- :- :/:::- ;:i riifi: :':■: :lr Lyvl:: - I: 1- !':- 
pares for himself solutions of grape sugar of different 
strengths, and makes the tests L K H in tubes of 
the same size, he can easily form a scale of the percent- 
ijr : -•:!•;:.: -r-:: ~'iii;l —ill 1- :.v".>r -,-:>:".•::. 77. 
Treat two parts of each sugar solution with one part 

ill'. A 
—ill oe :•■■ 1 : r-r-i ViLiry-y-ii : ~ : i - — : j~: ;-i-. - In-ion, 
dark amber ; a fire per cent, solution, the color of dark 
Jamaica rum; and a ten per cent, solution becomes 
~ -,rl: "::.— - in i ' : i. /:-. ~ l_ii- ■.,'.'. -.*.•:::::> : i — : -:- 
eentage are more or less transparent. As the diabetic 



THE URINE. 119 

urine has a very light color, so by comparison with 
these solutions an approximative determination can be 
easily arrived at, with the help of the known specific 
gravity. 

Sugar in large amount occurs in only one group of 
diseases, namely, glycosuria. A temporary glycosuria 
occurs after many lesions of the brain, and also a small 
amount in acute febrile processes, after spontaneous 
gangrene, pneumonia, typhus, rheumatism, and acute 
encephalitis ; in affections of the nervous system, espe- 
cially of the spinal cord ; in cachexies and similar pro- 
cesses ; also after the introduction of turpentine, nitro- 
benzole, nitrite of amyl, etc. 

Neukomm and Vohl have exceptionally found ino- 
site in diabetic urine, either with or in place of grape 
sugar. Also in acute Bright' s disease inosite has been 
found in the urine. 

[This substance (also called muscle sugar) has been 
found in muscle, lungs, spleen, liver, kidneys, and brain ; 
and, in addition to the before-mentioned diseases, it has 
also been detected in cases of phthisis, syphilitic ca- 
chexia, typhus, and disease of the medulla, also in two 
cases of tumor in the vicinity of the fourth ventricle ; 
although in a case of polyuria, with inflammation of the 
fourth ventricle, Pribram (as quoted by Beliield, " Dis- 
eases of the Urinary Organs," p. 128) was unable to 
detect either glucose or inosite. In several cases of 
inosituria, without any tangible disease, Ralfe observed 
moderate but not excessive polyuria, general malaise, 
and always considerable aching of the limbs. The full 



120 ANALYSIS OF THE URINE. 

pathology of this disease (if it may be called such) is 
as yet but little known. 

Inosite crystallizes in large rhombic tables or trans- 
parent, colorless prisms, is not fermentable by yeast, 
but is capable of lactic-acid fermentation, and in aque- 
ous solution is optically indifferent. A solution of 
inosite evaporated with nitric acid almost to dryness, 
the residue being moistened with a little ammonia and 
chloride of calcium, and again evaporated carefully to 
dryness, will yield a vivid rose-red color, which is ap- 
parent with one milligramme of inosite (Scherer). Ac- 
cording to Cloretta, Ralfe, and Oliver, it is inosite which 
causes the green color (followed by a light greenish pre- 
cipitate and return of blue color to the supernatant 
fluid) sometimes observed in using Fehling's test. Re- 
boiling this precipitate will cause the same change of 
color. For further details, see Neubauer and Yogel, 
edition 1881.] 

The breath of many diabetics has an odor like chlo- 
roform. Their fresh urine has the same smell after 
standing a short time. It is colored dark reddish- 
brown with iron chloride. In the distillate of such 
urine, acetone and alcohol are found, which may arise 
from the breaking up of ethyl diacetate : 

C H 10 O 3 + 2H 2 = C 3 H c O + C 2 H 6 + C0 2 + H 2 0. 

Ethyl diacetate. Acetone. Alcohol. 

[Lactose occurs in crystalline form (right rhombic 
prisms terminated by octahedral points), is not very 
soluble in water (1 part to 6 cold water), and precipi- 



THE URINE. 121 

tates alkaline copper solutions and indigo-carmine. It 
does not undergo the alcoholic fermentation easily with 
yeast but readily undergoes the lactic fermentation, 
and has a dextro-rotatory power of 59*3°.] 

In women, milk sugar (lactose) appears in the urine 
from twenty-four to forty-eight hours after the weaning 
of children, or as soon as from any cause the milk is 
not sufficiently gotten rid of (lactosuria). 

[LaBvulose (obtained from invert or fruit sugar) 
has been occasionally observed in the urine of persons 
having the symptoms of diabetes, with or without glu- 
cose. It reduces cupric- sulphate solutions as glucose, 
but may be distinguished from the latter by its left- 
handed polarization, care, of course, being taken to 
exclude other lsevo-rotatory substances. Its power of 
polarization diminishes with elevation of temperature, 
being 106° at 14° C, 79*5° at 52° C, and 53° at 90° C. 
Its clinical significance is unknown. 

Of late the occurrence and pathological significance 
of acetonuria and diaceturia have attracted a good deal 
of attention, and von Jaksch * has done much to ad- 
vance our knowledge of the subject, which is still, how- 
ever, rather obscure. He believes that the volatile sub- 
stance which Lieben says is contained in the distillate 
from normal urines, and from which iodoform is ob- 
tained by the action of sodic or potassic hydrate and 
iodine, is acetone, and is therefore to be considered a 

[* "Bericht der deutsch. cheui. Gesellschaft," 1882, p. 1492, and in 
other publications more recently. See especially a summary of his views 
by Dr. P. C. Griffith (" Philadelphia Medical News," October 3, 1885).] 



122 ANALYSIS OF THE URINE. 

constant and normal product of tissue metamorphosis. 
He Las also obtained a slight iodoform reaction from 
the blood of living and dead persons. The amount in 
the mine of a person in health is, however, probably 
not more than 0*010 grm. This may be increased in 
diabetes mellitus, hydrophobia, carcinoma, and the so- 
called "acetonemia? It is found in relatively large 
quantities in the distillate from febrile urine, as a 
rule several decigrams ; and the degree rather than 
the kind of fever influences the amount. The best 
method to detect it is probably Lieben's : To a por- 
tion of the distillate of urine add a small quantity 
of liquor potassae, and then a few drops of a solution 
of iodine and potassium iodide. A yellow precipitate 
will at once occur if acetone be present. The pres- 
ence of alcohol will delay the formation of the pre- 
cipitate.* 

Jaksch has also found that the substance in many 
urines which gives the Bordeaux-red with ferric chlo- 
ride^ and which on warming gives acetone, is diacetic 
acid, and that its occurrence in the urine in disease is 
a very serious complication. It has been noticed in 
mental diseases with excitement, with inanition and 
carcinoma, and especially in diabetes mellitus, although 
there seems to be no relation between the amount of 
su^ar and diacetic acid eliminated. Sometimes a sud- 

o 

[* Baginsky found acetone in normal urine of children, and regards its 
presence as intimately connected with protein waste. 

t According to Le Nobil, formic acid, often present in diabetic urine, 
gives a similar reaction with ferric chloride ("American Journal of Medi- 
cal Sciences," vol. xciii, p. 239).] 



THE URINE. 123 

den diminution of glycosuria is succeeded by an in- 
crease in the amount of diacetic acid in the urine, coma, 
and death. He considers what is usually known as 
diabetic coma to be due to the presence in the blood 
not of acetone, but diacetic acid, and he proposes to 
substitute " coma diaceticum" for "diabetic coma" in 
all cases accompanied by diaceturia. It is not to be 
forgotten, however, that diabetic coma sometimes oc- 
curs without either acetonuria or diaceturia. 

His method of detecting diacetic acid is this : Take 
a freshly voided sample of urine, and to a small por- 
tion add a few drops of a solution of ferric chloride. 
If the phosphates are precipitated, filter them off, and 
to the filtrate add a few more drops of ferric-chlo- 
ride solution. If a red color is produced, boil a por- 
tion of the urine, and to another portion add a few 
drops of sulphuric acid, and shake up with ether. If 
the red color appears but slightly, or not at all, in the 
boiled portion, and grows pale after twenty-four hours 
in the ethereal extract, and, furthermore, acetone is de- 
tected in considerable quantity in the distillate, we have 
to do with diacetic acid. 

As opposed to Jaksck's results, however, Frerichs * 
found that the introduction of acetone and aceto-acetic 
acid into the bodies of animals was followed by no bad 
effects, and that considerable quantities had to be given 
before the urine reacted for acetone; and K. Alber- 
toni f very recently states that he finds acetone is not 

[* "Zeit. fur klin. Med.," Bd. VIL, Snppl., 1883. 

t Quoted in " Boston Medical and Surgical Journal," October 15, 1885, 
from "Journal of Chemical Society of London," June a 1885.] 



124 ANALYSIS OF THE URINE. 

injurious, and even in large doses only produces intoxi- 
cation. When given to healthy persons in doses larger 
than 3 c.c, it passes unchanged in the urine. Ethyl 
aceto-acetate, or aceto-acetic acid, produces nothing like 
diabetic coma, but sometimes causes the urine to become 
albuminous. Oxy butyric acid, a lsevagyrate body which 
reduces copper salts, is considered by some to be the real 
cause of diabetic coma. They claim it has been fre- 
quently mistaken for diacetic acid in diabetic urine.] 

3. Leucine and Tyrosine. 

Leucine (C 6 H 13 N0 2 ) and tyrosine (C 9 H n N0 8 ) are 
the decomposition products of the albuminous bodies 
and their derivatives. We find both these substances 
in several glandular organs of the body, especially if 
they have been subjected to certain pathological changes ; 
for instance, in the liver, pancreas, and spleen. In urine 
these substances have as yet been noticed in any great 
quantity only in acute atrophy of the liver and in a few 
cases of phosphorus-poisoning. Small quantities are 
observed in typhus and small-pox. 

If these substances are present in great quantity in 
the urine (as is generally the case in acute atrophy of 
the liver), the proof of this is veiy easy. We either 
find the crystalline tyrosine already in the sediment, or 
it sermrates together with the leucine if we evaporate 
the urine on a water-bath to a small bulk. Sometimes 
both bodies are found in such large amount in the urine 
that they almost supplant the urea. They are easily 
recognized microscopically from the evaporated urine 



THE URINE. 125 

by tlie characteristic form of their crystals. (PI. IV., 
A.) 

If these substances are not present in so large quan- 
tity that they separate by simple evaporation of the 
urine, then we take a great bulk of the latter. If rich 
in bile pigments and albumen, the urine is treated with 
a solution of basic acetate of lead, filtered, and the fil- 
trate treated with hydrogen sulphide to remove the ex- 
cess of lead, filtered again, and the clear filtrate evapo- 
rated on a water-bath to small bulk. If tyrosine is 
present, it crystallizes beautifully after standing twenty- 
four hours. Leucine, which is much more soluble than 
tyrosine, appears much later. The urine must be as 
fresh as possible to work upon. 

The presence of leucine and tyrosine in large amount 
indicates a considerable destruction of the proteine sub- 
stances. Albumen for the most part accompanies them. 
Often oxymandelic acid (C 8 H 8 4 ) also occurs — a sub- 
stance nowhere else observed, and which is perhaps a 
derivative of tyrosine. 

4. Abnormal Coloring Matters, 

Among the abnormal coloring matters, we are to dis- 
tinguish between those which occur normally in other 
fluids of the body, as the blood- and bile-coloring mat- 
ters, and those which are only found in the urine, as 
ui-oeiythrine, and plant-coloring matters accidentally 
excreted by the same. 

a. Uroerythrine (Harletfs urohoematine). In all 



126 ANALYSIS OF THE URINE. 

febrile diseases the urine has a more or less dark 
reddish-yellow color (urina flaramea), and an expert is 
able to diagnose in most eases a febrile state from the 
urine alone. This color arises, according to Heller, from 
uroerythrine (as well as from an increase of the normal 
coloring matters). If on cooling a deposit of urates 
occurs, they are mostly rose-colored to dark red. On 
addition of lead acetate to clear urine, the precipitate 
appears flesh-colored or rose-red. Heller calls this red 
coloring matter of the urine, which colors the brick- 
dust sediment and is also found in solution, uroery- 
thrine. 

This coloring matter should contain iron, but its con- 
stitution and mode of origin are unknown. It is possible 
that in febrile processes, especially such as are accompa- 
nied by blood-dissolution (typhus, septic fever, etc.), a 
part of the blood-corpuscles by their retrograde meta- 
morphosis furnish the material for the formation of the 
uroerythrine. 

The uroerythrine may be regarded as an indication 
of the breaking down of the blood-corpuscles in febrile 
processes. 

Uroerythrine is recognized when present by the color 
of the brick-dust sediment, or, if no sediment be present, 
by the color of the solution, in which if treated with 
acetate-of-lead solution a rose-red or flesh-colored precipi- 
tate falls. Only a little of the lead solution should be 
added, so that the coloring matter shall not be disguised 
by tor> much of the precipitate. If the urine contains 
the blood-coloring matters, these must be first separated. 



THE URINE. 127 

The foam of a urine containing much uroerythrine may 
be yellow as in icterus ; but with the latter the precipi- 
tate from the lead salt is also yellow. 

The earthy phosphates which are thrown down by 
heating the urine with KOH appear gray, while if the 
urine contains blood-coloring matters they are blood-red 
or dichroic. The absence of albumen in the urine, the 
gray color of the earthy phosphates, and the red pre- 
cipitate from lead salt, serve as points for the differen- 
tial diagnosis between uroerythrine and blood-coloring 
matters. 

Uroerythrine occurs in all febrile conditions, even 
in the lightest catarrh, but most abundantly in pyae- 
mia, liver affections, and lead colic. 

j3. The Vegetable-coloring Matters. — Many vegetable- 
coloring matters, especially chrysophanic acid (in rhu- 
barb and senna leaves), impart to alkaline urine a 
reddish-yellow to deep red-color. These are easily rec- 
ognized from the fact that on the addition of an acid 
the urine loses its color, which returns again upon addi- 
tion of an excess of ammonia. After heating with 
KOH, if a precipitate of earthy phosphate falls, it is 
often colored blood-red, so that one might be induced 
to believe there was blood-coloring matter in the urine. 
The precipitate never appears dichroic, but by long 
exposure to the air becomes violet.* 

The fact that the urine loses its color by addition 

[* Santonin also imparts a bright yellow or greenish-yellow color to 
urine, which might induce one to think bile-coloring matters present ; but 
the addition of ammonia imparts a red or purplish-red color in the former 
case. A similar reaction occurs with madder, gamboge, and logwood.] 



L28 A XA LYSIS OF THE URINE. 

of an acid, and regains the red color upon addition 
of an excess of ammonia, and that it contains no albu- 
men, distinguishes this reaction from that of the blood- 
coloring matters and uroerythrine. It is of importance 
for the physician to know this reaction, especially in 
summer, when the urine is apt to have an alkaline re- 
action and the blood-red appearance to cause alarm. 

7. Blood-coloring Matters. — The appearance of blood- 
coloring matters in the urine may be from a double 
origin. They may have been excreted by the kidneys. 
or may have arisen from the breaking down of blood- 
corpuscles in the urine. The color of this urine is 
different according as haeinoglobine or inethaemoglobine 
is present in the mine. 

From haemorrhage of the large vessels the urine 
contains mostly haeniogiobine. By parenchymatous or 
capillary haemorrhage the mine almost always contains 
some inethaeinoglobine, which imparts to the fluid a 
brownish-red color. The reason that at one time haeino- 
globine alone, and at another with methaemoglobine 
also, appears in the mine, may be due to the fact that 
with capillary haemorrhages, which occur in various 
kidney affections, the blood becomes more slowly and 
intimately mixed with the urine, and is held longer in 
solution at the normal temperature of the body in the 
organism. The temperature and carbonic acid of the 
mine, as well as the lack of oxygen, furnish the essen- 
tial conditions for the change of haemoglobine to metha> 
moglobine. 

In order to prove the presence of the blood-coloring 



THE URINE. 129 

matters in the urine, the hsemine test is useful. The 
earthy phosphates are precipitated in a test-tube by- 
adding KOH with slight warming. The earthy phos- 
phates carry the blood-color substances to the bottom 
of the tube, and consequently do not appear white as 
in normal urine, but blood-red. If but a slight amount 
of blood-coloring matters is present in the urine, the 
precipitate will appear dichroic. 

If an alkaline urine is evacuated, and by heating 
with KOH no earthy phosphates are separated, from 
the fact that they have been already deposited, we may 
by addition of a few drops of the magnesium solution 
form an artificial precipitate in the KOH mixture, 
which will by warming bring down along with it the 
blood-color substances just as well as do the earthy 
phosphates. 

The precipitate containing the coloring matters of 
the blood should be filtered off and placed upon an 
object-glass, and warmed carefully until the phosphates 
are perfectly dry. Then the hsemine crystals can imme- 
diately be separated. For this purpose a few grains of 
common salt (Na CI) are rubbed into the dried earthy 
phosphates containing the coloring matters ; the excess 
of salt is then blown off the object-glass, and a hair is 
laid across the residue. A glass cover is laid on, a drop 
of glacial acetic acid added, and the slide warmed until 
little bubbles begin to show themselves under the glass 
cover. After cooling, crystals of hsemine can be seen 
under the microscope. Extreme care must be taken in 
this test, upon addition of KOH to the urine, to warm 



130 ANALYSIS OF THE URIKE. 

but slightly and filter rapidly, to avoid further decom- 
position of the blood-coloring matter. When the glacial 
acetic acid is added, gas bubbles form before heating, 
which are simply carbonic-acid gas. These are allowed 
to pass away, and then we heat to the bubble forma- 
tion spoken of above, i. e., to the boiling point of acetic 
acid. The haemine crystals obtained in this way often 
appear small and imperfectly crystallized, but with a 
high objective they are easily recognized. (PI. V., A, 
1, and Hofmann, 1. c, 295.) 

This can be done in another way as follows : Render 
the urine alkaline with NaOH, add tannic-acid solution, 
and then acetic acid. The washed and dried precipitate 
is treated for haemine. 

For the proof of blood-coloring matters in urine, 
separate the albumen by heat and coagulation, collect 
the brown coagulum on a filter, dry, and extract with 
alcohol containing some sulphuric acid. Permit the 
alcohol to evaporate. From the residue Teichmann's 
crystals of haemine may be separated as above de- 
scribed. (See Appendix D.) 

If a spectroscope is at hand, it is very satisfactory for 
the proof of the blood-coloring matters. The urine 
should be diluted and put into a large test-tube, and 
held between the slit and a petroleum lamp. (" Spec- 
tralbild des Methaemoglobin," K. B. Hofmann, 1. c, 277, 
erste Abbildung, Nr. II.) 

The so-called haematinuria (the passage of blood- 
coloring matters into the urine) occurs with constitu- 
tional diseases, such as scurvy, purpura, scarlatina, etc. 



THE UBINE. 131 

It is hardly necessary to add that after transfusion of 
blood, after inhalation of hydrogen arsenide, and also 
with true haematuria, soluble blood-coloring matters are 
mixed with the nrine. 

[Melanin has been met with in the urine of persons 
suffering from melanotic tumors and after repeated at- 
tacks of ague. Melanin deposits in the urine in minute 
lumpy granules, which are soluble in liquor potassae 
and its alkaline solution, is decolorized by passing a 
stream of chlorine through it. Its solubility in liquor 
potassae distinguishes it (Ralfe) from carbon granules, 
coal dust, or soot, sometimes accidentally mixed with 
urine.] 

8. Biliary -coloring Matters. — Under certain condi- 
tions the coloring matters of the bile may be mixed 
with the urine. The urine more frequently contains 
biliprasine than bilirubine, but not seldom other oxida- 
tion products. If unchanged bilirubine is present in 
the urine, by a simple test we obtain a beautifully 
characteristic color-reaction. If biliprasine is present, 
by the same test we only have a green color. If the 
biliary-coloring matters are further changed, the test 
entirely fails. 

1. Gmelirts Test. — Into a small test-beaker contain- 
ing the icteric urine we pour a sub-layer (in the same 
manner as we perform the test for albumen, by pouring 
the acid slowly down the side of the glass) of strong 
nitric acid, containing a little yellow fuming nitric acid 
(HN0 3 -|-X0 2 ). In the zone between the fluids there 
occur from below upward the colors green, blue, violet, 



132 ANALYSIS OF THE URIXE. 

red, and yellow. The green is predominant, whereas 
the blue often does not appear. This test can also be 
made by adding weaker HN0 3 to the urine in a beaker, 
and then pouring under this mixture a layer of concen- 
trated K 2 S0 4 . 

2. HeEerts Test. — Pour into a small beaker-odass 
about 6 c.c. of pure HC1, and drop the urine into it 
until the acid is distinctly colored. Stir this, and 
beneath the mixture pour a layer of pure HX0 3 . In 
the intermediate zone there occurs a beautiful irides- 
cence. If we now stir with a glass rod, the entire mix- 
ture shows the color-changes successively in the same 
order as they had been previously observed between the 
fluids. This may best be seen by transmitted light. 
This test is very delicate, easily applicable, and suffices 
for most cases of urinary investigation. 

To detect the presence of but a small quantity of 
biliary coloring matters, 100 c.c. of mine must be gently 
agitated with 10 c.c. of chloroform in a flask, until the 
chloroform is colored yellow. Strong shaking is to be 
avoided, so that the chloroform will not break up into 
small drops, which will not again resolve themselves 
into a clear fluid. By closing the tube with the thumb 
and inverting the flask, it is easy to pour off about 1 c.c. 
of the colored chloroform into a test-tube containing 10 
c.c. of pure HC1, when the yellow chloroform drops will 
sink as a colorless fluid to the bottom. If now with 
slight movement we add a little HN0 3 , the chloroform 
at the bottom of the fluid will go through all the spec- 
tral color-chancres which are shown in Gmelin's test. 



THE URINE. 133 

For the reason that the changes take place very slowly, 
and because acids work but slowly upon biliary coloring 
matters dissolved in chloroform, this reaction is especially 
good for demonstrating the biliary color scale. 

In all reactions upon the unchanged coloring matters 
of the bile, the green color is characteristic. If this is 
not recognized, we can not be sure concerning the pres- 
ence of these coloring matters. Urine rich in indican 
gives also with Heller's test a play of blue, violet, and 
dirty reddish-yellow. The characteristic green of the 
bile matters is, however, not perceived when only indican 
is present. 

If we test for albumen by pouring under the urine a 
layer of HN0 3 in a wine-glass, we see, when the un- 
changed bile-coloring matters are present, a green band 
between the fluids. If albumen also is present, its zone 
is colored green from the biliary coloring matters. 
Urine rich in indican may mislead as to the biliary 
color-reaction. There appears in the same position 
between the fluids an indigo-blue color, which in re- 
flected light may be easily mistaken for green. In such 
doubtful cases the biliary matters are to be isolated, as 
before mentioned, by chloroform and proved by Heller's 
test; or the urine may be treated with lead solution, 
and the filtrate tested for indican. 

3. JJltzmanvbS Test. — This test simply shows the 
characteristic green color with distinctness and cer- 
tainty. We add to 10 c.c. of urine 3 or 4 c.c. of a pure 
KOH solution (1 part of caustic potash to 3 of water is 
essential), then shake and add an excess of pure HC1. 



134 ASALYSm OF TEE TTRl 

The mixture now assumes a beautiful enierald-gi 
color.* 

In icteric urine the precipitated earthy phosphates 
are colored brown by the biliary coloring mati 

The presence of altered biliary coloring matters 
(Jjilifuseine). i. e., such as no longer give the reactions 
of Ginelius and Heller's nay be ascertained as 

follows : A clean white Hnen cloth (or filter-paper) is 
dipped into the urine and allowed to dry; the linen 
appears colored brown. The presence in the urine of 
altered biliary coloring matter causes also a very dark 
H 2 S0 4 reaction : the urine does not appear garnet-red, 
but almost black. A similar reaction occurs in the 
presence of sugar and blood -coloring matters. 

Finally, if the urine is warmed with KOH and the 
earthy phosphates fall, the urine is colored much darker 
than before the heating, and the precipitate of phos- 
phates is colored brown. 

Biliary coloring matters are found in the urine in 
various pathological processes of the liver, whether 
or not there exists an icteric coloring of the skin. 
Thus icterus can be prognosed one or more days in 
advance by the appearance of the urine. Further, 
these coloring matters are always present in phos- 
ph orus-poisoning. 

[M. Xeucki and X. Lieberf have observed a new 

{* Marechalf* Test depends upon the production of an emeraL. 
color when to an icteric urine are carefully added a few drops of tincture 
of iodine, or a solution of bromine mar be used instead of iodine (Laache, 
u Harn- Analyse," p. 126). 

Jour, fur praktische Cbemie," 17, 18.] 



THE URINE. 135 

coloring matter, which they propose to name uro-rosein. 
They first obtained it from a patient suffering from a 
severe form of diabetes niellitus, but afterward failed to 
find it in four other cases of the same disease, but have 
met with it in about ten per cent, of all pathological 
urines examined by them. They consider the reddish 
color produced by the addition of 5-10 c.c. of a twenty- 
five per cent, solution of sulphuric or hydrochloric acid 
to 50-100 c.c. urine as indicative of its presence. The 
substance seems to exist in the form of a sulpho-acid, 
and to resemble the rosaniline colors. Its other chemi- 
cal properties and its spectroscopic appearance are de- 
tailed in their article. 

Neusser * has observed, in a case of chronic pleu- 
risy, a substance which he regards as hsematoporphyrin, 
or a body nearly akin to it. The urine was blood-red 
in color, acid in reaction, and contained no albumen. 
The chemical reaction and spectroscopic appearance are 
given in the article. 

P. Plosz thinks he has detected, in the urine of a 
case each of cysto-pyelitis with parenchymatous nephri- 
tis and chronic peritonitis with effusion, a substance, 
perhaps identical with the scatol derivative, which 
Brieger found in the urine of rabbits. The peculiarity 
of the urine was that, on exposure to the air, it became 
greenish-brown from the surface downward, and this 
coloration disappeared on exclusion of the air. When 
the urine was exposed in thin layers to the air it took 

[* Abstract in " Zeitschrift fur analyt. Chemie," 1882, p. 476.] 



136 ANALYSIS OF THE URINE. 

on a reddish color, which was constant. For other par- 
ticulars regarding it, see Plosz article (" Zeitschrift fur 
phys. Chemie," Vol. VI., pp. 504-507).] 

5. The Bile Acids. 

The bile acids appear very seldom in the urine, and 
when found exist in extremely small quantity. In 
icterus they are rarely found, although the biliary color- 
ing matters are present in large amount. In parenchy- 
matous affections of the liver, on the contrary, which 
are followed by a rapid destruction of that organ, the 
bile acids are undoubtedly present, but in very small 
amount even then. 

It must be accepted that in these cases so much of 
the bile acids are formed that, the blood being unable to 
assimilate them, some are excreted unchanged. 

Sometimes it happens that we are able to prove the 
presence of the bile acids by Strassburgers' method, as 
follows : Dissolve some cane sugar in the urine to be 
tested, dip in a piece of filter paper, and permit it to 
dry. If now we touch the paper with a glass rod 
dipped in H 2 S0 4 (free from HN0 8 ), we perceive a pur- 
ple-violet stripe (a red or reddish brown color is not 
decisive). 

Usually the bile acids must be isolated from a great 
amount of urine and proved by Pettenkofer's test. 
The method of procedure is very complicated. About 
500 c.c. of urine are evaporated on a water-bath to dry- 
ness, and the residue extracted with alcohol. This solu- 



THE URINE. 137 

tion is again evaporated, and the residue again taken up 
with absolute alcohol. The alcoholic solution is again 
evaporated, and the residue dissolved in a little water, 
and treated with lead-acetate solution, avoiding an ex- 
cess ; the precipitate is collected, washed, and dried on 
filter paper. The biliary lead salts are then extracted 
with boiling alcohol. The solution after treating with 
carbonate of sodium is evaporated, and the sodium 
biliary salts thus formed extracted with absolute alco- 
hol. This is now evaporated, and to the very highly 
concentrated aqueous solution of the residue we apply 
Pettenkofer's test, which depends upon the fact that 
when the watery solution of all biliary acids is treated 
with a few drops of a concentrated cane-sugar solution, 
and after that with a few drops of concentrated H 2 S0 4 , 
the solution is colored purple-violet, if we take care that 
the mixture is not heated above 50° C. It is a good 
plan to place the dish or test-tube in cold water before 
the addition of the H 2 S0 4 ; for otherwise the sugar may 
be carbonized by the H 2 S0 4 and a blackish-brown solu- 
tion ensues. 

The merest trace of these acids may be discovered 
by Neubauer's modification of this. A few drops of the 
solution to be analyzed are evaporated to dryness in a 
porcelain dish over a water-bath. Add now a drop of 
a cane-sugar solution (1 grm. sugar to 500 c.c. water), 
and as much concentrated H 2 S0 4 ; warm them on a 
water-bath until the edge shows a violet color, then 
remove, and the reaction goes on. 

A large number of other substances, as amyl, al= 



138 ANALYSIS OF TEE UBHTR 

eohol, albumen, and ol _ive similar reactions. 

The spectroscope shows, however, an essential differ- 
ence. | S. Hofknann, 1. c. 195 

[The practitioner who has had much experience 
with our present methods of testing for bile acids will, 
no doubt, welcome a more simple an te-t 

for their presence. Such a one seem? to have been de- 
vised by Dr. G ' Oliver." To detect the presence 
of these substances, he utilizes the physi I gical fact 
that the products of gastric digestion | pej and pro- 
peptone) are precipitated along the lining of the duode- 
num, by the action of the bile acids on the acid d:_ 
tive fluid. Since albumen and peptone in an acid solu- 
tion (as in the urine^) are precipitated by the bile acids 
or their derivative — cholate of sodium— obviously an 
acid solution of them (of the two. better peptone) 
may be used as a test for the bile acids. Hence Dr. 
Oliver has devised the following test-solution, which 
i- antiseptic : 

Pulverized peptone (Savery and H : . gr. xxx. 

Salicylic acid gr. iv. 

Acetic acid ~;xxx. 

Distilled water to iz riij. 

To be filtered repeatedly until transparent. 

To apply the te-t. the urine must be rendered per- 
fectly clear, by boiling or filtration if necessary, and 
rendered acid if alkaline ; and the specific gravity re- 
duced to 1008 if above it. Then to 60 minims of * 

[* M Lancet," March 7. 1885, ti *eq., and 'Bedside Urine-TestiDg." third 
edition.] 



TEE URINE. 



139 



fluid 20 minims of urine mixture are added. If bile 
salts are present in subnormal or normal quantity, there 
is no immediate reaction, but in a little while a slight 
tinge of milkiness is produced. If they are present in 
abnormal amount, a distinct milkiness promptly ap- 
pears, becoming more intense in a moment or so, the 
degree of opacity being proportionate to the amount 
present. On agitation the opalescence diminishes, and 
may disappear, but reappears on the addition of more re- 
agent. On this fact he bases a rough quantitative test, 
for which he prepares a standard solution by adding 
equal parts of test-fluid and normal urine mixture of 
specific gravity 1008. Any urine requiring 60 minims 
or more to bring its opacity up to that of the standard 
does not contain an excess of bile acids. He has pre- 
pared a standard table as follows : 



If 1 minim or 2 drops are required, 
2 minims or 4 " " 



3 < 


6 


4 


8 


5 < 


10 


10 < 


20 


15 


30 


20 


40 


25 ' 


50 


30 


60 


35 


< 70 


40. 


80 


45 < 


90 



INCREASE OF PERCENTAGE. 


1, . . 6,000 times. 






3,000 


a 






. 2,000 


a 






. 1,500 


u 






1,200 


u 






600 


a 






400 


a 






300 


u 






240 


u 






100 


u 






83 


a 






66 


a 




i 


50 


u 



1-40 ANALYJBT8 OF THE UBINK 

An increase over 700 per cent, is rarely found in 
urine. 

This test is so delicate that Dr. Oliver detects 1 
part of bile salts in 18,000 to 20,000 parts of a solution 
of -odium chloride. He has also a peptone test-paper 
with those for sugar and albumen. 

The precipitate caused by the bile acids differs from 
all others produced with this reagent in dissolving on 
the addition of a drop or so of acetic acid, and by 
diminishing, but not disappearing entirely, on boiling. 
If his directions as to the preparation of the urine are 
carried out, nothing he has yet found in the urine in- 
terferes with this test. He finds the bile acids excreted 
in increased quantity in normal urine during fasting 
and after exercise, and in pathological urine in jaun- 
dice, fever, functional diseases of the liver (acute and 
chronic biliousness), organic disease of the same (car- 
cinoma, enlargements generally, cirrhosis, and amyloid 
degeneration), and hsemolytic disease (simple and ma- 
larial ansemia and splenic leucocythemia).] 

Sometimes, besides the above-mentioned substances, 
also appear allantoin, especially after use of tannic acid, 
lactic, acetic, and butyric acids, with acid fermentation, 
benzoic acid in fetid urine, and sometimes also fat and 
soap. 

6. Carbonate of Ammonium. 

All the ammonium carbonate, ( XH t ) 2 C0 3 , which is 
found in the urine arises from the breaking down of 
the urea. Urea is carbamide — 



THE URINE. 141 

NH 2 
X NH 2 

By taking up water, urea is changed into carbonate of 
ammonium — 

( NH 2 ( O.NH 4 

CO-^ + 2H 2 = CO-^ 

( NH 2 ( O.NH 4 

This transformation of urea into (NH 4 ) 2 C0 3 is the 
explanation of the generation of ammonia by the 
changes of the urine through decomposition under some 
circumstances in the bladder. A body adhering to 
the mucous membrane of the bladder acts as a ferment 
under certain conditions. This is especially the case in 
bladder catarrh. We find that in most bladder affec- 
tions the urine possesses an alkaline reaction. The 
catarrhal secretion from the pelvis of the kidney does 
not appear to give rise to an alkaline fermentation of 
the urine, except in very advanced stages. We conse- 
quently find that in pyelitis, in contradistinction to 
bladder catarrh, the urine almost always has an acid 
reaction. If we take two equal parts of fresh normal 
urine and add to one the sediment from a freshly-passed 
pyelitic urine, and to the other the sediment from a 
freshly-passed cystitic urine, and allow them to stand, 
at first we observe an acid reaction in both urines ; but 
after a short time the urine mixed with bladder secre- 
tion begins to lose its acid reaction, and in two or three 
hours will have become distinctly alkaline, while the 



:±i ¥ THE CE. 

nrinie with the an acid 

reaction and does not become alkaline usually until 
-. fi K enfl •:';« or hoars afterward. 

I.--: :: ammoninm appears in the second 
stage of acnce exudative processes as the so-called re- 
sorption nrme T widen may - regarded - i favorable 

:«::::. '_':;::- :ontainiiu :!:- *howg srenerallv an alka- 
Else reaction. Sinee r however, the alkaline reaction 
may "be caused "by erne of the fixed alkalies, as earbc 
: v:.i:~zi ~ "_::'_ i_.~y i:-~r ' 7-1 :.•>-' :"■-::: -•!'.- .in": 
- ■ . - : ■ . ■ ■ " - : « - ■ the origin of the alkalinity : 
the nriae, we may apply the folio win _ t 

Poor into a flask of 100 cjc capacity 15 to 20 c 
the urine to be analyzed, and close the flask with a 
:lr -;_"_ —'_:;'_ > ~ ;— -: ; : rn- ~:~ - :n- "liikzrss : * 
lead pencil. Into this introduce a strip of m 
fitmns paper, and gently warm the flask on a water-bath. 
H ammonia is present, it will be drawn off with the 
steam, and the red Ihmos paper will be colored blue. 

In •"_:- ~ • •:- .' '.- " :•-■:■ jn:.:- • "-r~ -n_..-ll ■:.■:;- 

■ " - nia in the nrine. Care most be taken that 

the mine does not boil, for then the urea would be 
decomposed and ammonium carbonate would be form 
f ammomam is present— 
(1 irious bladder affection 

. | In the second stage of acute exudative processes 
i"-:S ?~ ". n '::;n- . 

A:-: :- : : j t HeHer,anmi mum sarbonate is present 



THE URINE. 143 

also in spinal affections and in severe typhus, the urine 
possessing an acid reaction. 

7. Sulphuretted Hydrogen. 

Sometimes we find in albuminous urine, especially 
with bladder catarrh, where a great amount of pus is 
produced, sulphuretted hydrogen (H 2 S). It is formed 
from the decomposition of the albuminous bodies within 
the bladder. Although this may be recognized by its 
odor alone, it can be proved chemically by the same 
means above described for the detection of carbonate of 
ammonium. Instead of the litmus paper that we em- 
ployed above we must substitute a strip of white filter 
paper moistened with a drop of a solution of lead or sil- 
ver salts. Upon the addition of the slightest heat the 
H 2 S escapes and colors the white paper in the tube 
black-brown. These urines are betrayed by coloring 
silver catheters black. 

8. Accidental Constituents. 

By accidental constituents of the urine we under- 
stand those bodies which are exceptionally taken into 
the organism and evacuated by the urine. 

Many substances undergo no essential change in the 
organism, including most inorganic compounds, also 
many organic (succinic acid, chloroform, quinine, phe- 
nol, etc). 

After continued use of the heavy metals and their 
salts, and also after continued employment in contact 



144 ANALYSIS OF TEE URINE. 

with them (as color- workers, potters, etc.), antimony, 
arsenic, copper, zinc, gold, silver, tin, lead, bismuth, and 
mercury have been found in the urine. 

The alkali salts taken internally appear in the urine 
— the alkali carbonates, ammonium salts, chlorates, 
borates, and silicates of the alkalies, ferro- and ferri- 
cyanide of potassium, potassium cyanide and iodide, etc. 
Sulphur-hepar is excreted as a sulphate. Calcium and 
magnesium salts pass in but very small amount into the 
urine. 

The mineral acids (sulphuric, nitric, phosphoric, etc.) 
become for the most part excreted as the corresponding 
alkali salts. Only carbonic acid occurs free to any great 
extent in the urine. 

The metallic bases, which exist in but minute quan- 
tity in the urine, may be separated by the usual quan- 
titative analysis or by electrolysis. Arsenic may usually 
be detected by treating the urine with H 2 S gas and 
applying Marsh's test to the precipitate. 

Many compounds, especially organic, undergo an 
important change in the organism. The aromatic acids, 
for example, are excreted as glycocol combinations, just 
as benzoic acid is excreted by the urine as hippuric, and 
salicylic as salicyluric acid. 

The alkaline carbonates are found in tlie urine — 

(1.) After their internal exhibition. 

(2.) After use of sodium mineral waters. 

(3.) After a plentiful fruit diet, as the salts of 
vegetable acid are easily changed in the organism to 
carbonates. 



THE URINE. 145 

In these cases the reaction of the nrine is alkaline. 
Whether this alkalinity is dne to the breaking np of the 
urea, or has its origin from the fixed salts, we may 
determine by methods given on p. 48. 

We may also pour 10 c.c. of urine into a porcelain 
dish, and evaporate the same to dryness, dissolving the 
residue in a few drops of water. If this residue gives 
a strongly alkaline reaction, it is due to the presence of 
the fixed alkalies in the urine. If the residue gives an 
acid reaction while the fresh urine has an alkaline reac- 
tion, the alkalinity is due to (NH 4 ) 2 C0 3 , which is de- 
composed by evaporation. If we suspect the presence 
of other alkali carbonates, as well as the unstable am- 
monium carbonate, we must first test for the (NH 4 ) 2 C0 3 
in a flask as before described, and then test for the others 
in a porcelain dish. 

Iodine is very easily detected. If we add to a little 
urine in a test-tube some carbon disulphide (CS 2 ), and 
drop in bromine water or a small amount of fuming 
nitric acid, and after the addition of each drop close the 
test-tube with the thumb and invert, the violet color 
of the carbon disulphide (or chloroform) indicates the 
presence of iodine. 

We may also add to the urine thin starch paste and 
then a drop of HN0 3 . A blue or bluish-black color 
indicates the presence of iodine. Often, with Heller's 
test for albumen, iodine crystallizes out, partly on the 
side of the glass at the border of the albumen zone, and 
partly on the bottom of the vessel. 

Salicylic acid may be recognized by the violet color 

10 



146 ANALYSIS OF THE URINE. 

the urine assumes upon addition of ferric chloride. 
This is best recognized as follows : AVe add to 1 c.c. 
of a concentrated ferric-chloride solution in a test-tube 
10 c.c. of urine, and note the reaction. A similar reac- 
tion occurs, however, in many diabetic urines. (See 
p. 120.) 

D. THE SEDIMENT. 

Urine Fermentation. 

Normal urine is clear when passed. After stand- 
ing there forms on the bottom or lower half of the 
urine the so-called nubecula, a slight cloud of bladder 
mucus, which is easily distinguished if we hold the 
glass vessel against a dark background, as the sleeve 
of the coat, especially when in the mucus-cloud epi- 
thelium, bacteria, or the delicately precipitated urates 
are suspended. 

A healthy urine, if kept in a perfectly clean ves- 
sel exposed to the air (but better if air is excluded), 
will remain in this condition a long time (weeks or 
months). 

Often there takes place in the urine a change known 
as acid fermentation. 

The urine, besides the urate, contains the acid 
phosphate of sodium. If, now, this salt of phosphoric 
acid acts upon the sodium urate so that it extracts 
one part of the sodium, there results an acid salt 
of uric acid, which is difficultly soluble and falls to 
the bottom as a reddish-yellow or clay powder. This 



THE URINE. 147 

happens especially at a low temperature, but at a high 
temperature the decomposition process goes even far- 
ther; the uric -acid salt is deprived of all its base 
(sodium), and the almost insoluble uric acid sepa- 
rates in beautiful distinct crystals, which are more 
or less brick -red or dark brown, and fall to the 
bottom as a granular powder, a part sticking to the 
side of the vessel and part floating on the surface. Some- 
times the uric-acid crystals are mixed with the amor- 
phous powder of the undecomposed urates — sedimentum 
lateritivmi. 

While this process is going on no free acid is 
formed, as testing will prove. With the urine sedi- 
ment in most cases more or less small or great crystals 
of calcium oxalate are mixed (PL III., A). A part of 
the uric acid is in the organism transformed to oxaluric 
acid, which by long standing and exposure to air be- 
comes oxidized in the urine to oxalic acid, which ap- 
pears in the sediment as calcium oxalate. (This pro- 
cess, as may be understood, does not deserve the name 
of fermentation, though in a few cases a true fermenta- 
tion appears, with formation of acetic acid.) 

When the decomposition of the phosphates and 
urates is ended, there follows after a short time a new 
process. The urine becomes paler ; the crystals of uric 
acid have disappeared ; the acid reaction changes first 
to neutral, then to alkaline ; the urine gives off a 
strongly ammoniacal odor, becomes more and more 
turbid, and a whitish sediment falls, which no longer 
consists of urates, but of the phosphates of the alkaline 



148 ANALYSIS OF THE URINE. 

earths. By means of the microscope we find that this 
turbidity is not caused simply by the finely powdered 
suspended phosphates, but also by a multitude of 
partly quiet and partly ever-moving bacteria. This 
process is the characteristic or alkaline fermentation of 
the urine (PL IV., B). It is based upon the destructi- 
bility of urea by a peculiar ferment discovered by Mus- 
culus (Hofmann, 1. a, 400). 

Musculus recommends a paper saturated with the 
ferment as a very sensitive reactive for urea. The 
thick-flowing alkaline urine as it comes from bladder 
catarrh is filtered ; the filter paper which was used is 
washed with distilled water until it has no longer an 
alkaline reaction, dried, and colored with turmeric. The 
urea itself does not react on turmeric, but the urea is 
decomposed by the absorbed ferment, and the paper is 
colored brown by the resulting ammonium carbonate. 

Ammonia can combine with uric acid as urate of 
ammonia, which appears crystallized as single or double 
spheres with a smooth or thorny surface. If the am- 
monia formation goes on, then a part of the ammonia 
joins with the phosphate of magnesia and forms beau- 
tiful crystals of triple phosphate. The phosphate of 
calcium dissolved in acid fluid falls to the bottom in an 
alkaline solution. The sediment then of the alkaline 
urine consists of an amorphous mass of phosphate of 
calcium, together with crystals of triple phosphate ; 
at the beginning of the process also urate of ammonium 
is present. 

Blood and pus mixed with urine, as well as un- 



TEE URINE. 149 

cleansed vessels which have contained fermented urine, 
cause rapid decomposition of the same without having 
previously passed through the so-called acid fermenta- 
tion. Bacteria accompany this process, and well-devel- 
oped mold can be observed on the surface of the urine 
after it has stood for a time, especially on a hot day. 

Classification of the Sediment. 

As long as the formed constituents of the urine are 
distributed throughout the fluid they produce turbidity 
of the same ; as soon as they sink to the bottom they 
form the sediment or precipitate. Precipitation occurs 
in different urines with various degrees of rapidity : 
faster in thin than in thick albuminous urines ; more 
quickly if the materials are heavy solids, such as crys- 
tals of uric acid or the urates ; more slowly if they 
are light, as epithelium and delicate hyaline cylinders. 
The constituents of the sediment are either excreted in 
their present state from the bladder and only need to 
settle, or they may have had their origin in the evacu- 
ated urine. 

The elements of which the sediment is composed 
are either organized forms — and these appear as well 
in acid as (somewhat changed) in alkaline urine — or 
unorganized, partly amorphous, partly crystalline forms, 
some of which are found in acid and others in alkaline 
urine. 

Accordingly, we may classify all the sediments as 
follows : 



150 ANALYSIS OF TEE URINE. 

SEDIMENTS. 

I. From acid urine. II. From alkaline urine, 

A. NOT ORGANIZED. 

a. Amorphous: 

1. Urates of sodium and 1. Calcium phosphate. 

potassium. 

2. Fat. 2. Calcium carbonate. 

b. Crystalline : 

1. Uric acid. 1. Ammonium urate. 

2. Calcium oxalate. 2. Triple phosphate. 

3. Cystine. 3. Calcium phosphate. 

4. Tyrosine. 4. Magnesium phosphate. 

B. ORGANIZED. 

1. Mucus- and pus-corpuscles. 

2. Blood-corpuscles. 

3. Epithelium from the various tracts of the urinary 

apparatus. 

4. Cylinders (or casts) and fibrine coagula. 

5. Spermatozoa. 

6. Carcinomatous tissue. 

7. Entozoa. 

8. Fungi. 

These constituents will be considered according to 
their form and the frequency of their occurrence. 



TEE URINE. 151 



The Unorganized Sediment 
1. Urates. 

Uric acid is combined in the nrine with sodium and 
potassium, and forms in the sediment salts of varying 
composition ; for by a loss of part of the base (as we 
have described in the so-called acid fermentation) an 
acid salt arises, which is difficultly soluble and always 
tends to precipitate. 

The urates are more soluble in warm water than in 
cold, and the neutral salts are more soluble than the 
acid. Therefore it follows that the urates are most 
easily precipitated, if we add a strong acid which will 
deprive the neutral salts of part of their base, forming 
acid salts which are so difficult to dissolve. These 
become more easily precipitable the colder the fluid and 
the less the bulk of the urine. The formation of the 
urate sediment is favored by the three following con- 
ditions : 

1. Moderate acidity of the urine (by too strong acid 
reaction uric acid is precipitated), or the action of acid 
mineral salts (the so-called acid fermentation). 

2. Concentration of the urine, whether it be by 
addition of uric acid or by deprivation of water. 

3. Cooling of the urine, which condition may occur 
in the evacuated urine or in the dead body. 

The neutral alkali urates form an amorphous pow- 
der, which from the accompanying coloring matters 
appears yellowish, grayish-brown, or rose-red to brick- 



152 ANALYSIS OF THE URINE. 

red (sedimentum later itiuni). Under the microscope 
they have the appearance of fine grannies joined to- 
gether, resembling moss in structure. (PL V., B.) 

If there are strips of mucus on the object-glass with 
these granules imbedded, the beginner is liable to mis- 
take them for granular casts. They may be distin- 
guished by a less sharp contour, a less bodily consistence, 
and especially by the reaction of gentle heat. 

The sediment of urates disappears by application of 
heat. Should a residue remain, it is proved to be pure 
uric acid. Upon addition of some alkali (KOH or 
Na OH) and heat this also disappears. 

From this peculiarity of the urates they are distin- 
guished from pus and the phosphates. The phosphates 
can not be observed, however, if the urine is acid. In 
weakly alkaline urine, especially when made alkaline by 
KOH, on application of heat the phosphates precipi- 
tate. 

If the urine contains pus, it will not clear up by 
heating, but on the contrary the coagulated albumen 
renders it more turbid. (The alkalies prevent this 
coagulation.) 

Finally, we may also test the dried sediment by 
means of the murexide test (p. 57), or prove the pres- 
ence of urates by a pretty microchemical test, as follows : 
Add upon an object-glass to the spread-out urates a drop 
of hydrochloric acid, and in a short time observe the 
crystals of uric acid form in the field of the microscope. 

Sometimes we observe in the urine which has under 
gone the so-called acid fermentation, and is about to 



THE URINE. 153 

pass over into the alkaline, that the partly dissolved 
crystals of uric acid are set upon the prismatic crystals 
of acid sodium urate. 

A rare precipitate of crystalline acid urate of so- 
dium is observed sometimes in the strongly acid urine 
of children, the needle-like crystals being arranged in 
groups resembling sheaves of wheat. 

2. Urate of Ammonium. 

The acid ammonium urate is the only urate which is 
found in alkaline urine in connection with amorphous 
calcium phosphate and the triple phosphate crystals. 

Ammonium urate forms brown-colored spheres, which 
may develop singly or as double spheres, or which may 
exhibit a conglomeration of kidney-formed surfaces. 
The surfaces of such forms are smooth, or are studded 
with sharp points, resembling thorn-apples. The pro- 
longations may be long, branching, and bent, thereby 
forming a multitude of similar shapes (turnips, spiders, 
many -rooted teeth, etc.). (PL IV., B.) These forms 
are so characteristic that the observer after using the 
microscope remains no longer in doubt as to the nature 
of the sediment. 

The quantity generally admits of a few microchemi- 
cal tests. 

If a drop of HC1 is allowed to flow under the glass 
cover, the original bodies disappear, and after a short 
time we see the very small rhombic crystals of pure uric 
acid formed. If KOH is added instead of HC1, we 



154 ANALYSIS OF THE URINE. 

observe the formation of bubbles from the liberated 
ammonia. The urate of ammonia gives like the others 
the murexide test (p. 57). 

3. Uric Acid. 

The appearance of uric acid in the urine is in part 
dependent upon the same circumstances as the urates. 
Normally we find crystals of uric acid at the end of the 
so-called acid fermentation, also in concentrated urine, 
especially on summer days, when the higher temperature 
prevents the deposition of the urates. Finally, a patho- 
logical excess is found in those cases where the water 
and the alkalies do not suffice to retain it in solution. 

The primary form of uricacid crystals is that of 
rhombic plates with blunt rounded corners. This shape 
is known as the whetstone crystal. The crystals may 
be small and singly developed. Sometimes rows of 
these crystals are deposited on accidental impurities, as 
threads or hairs, and thus form long cylinders. In other 
cases the single crystals are developed and joined to for- 
eign matters, where they are arranged upon the edges 
(fan-shaped) or upon the faces (as tiles). Besides the 
whetstone crystals, we often find tub-shaped or long 
pointed crystals joined together in a rosette. (PL II., B.) 

The rough and pointed forms of uric acid have a 
great practical significance, inasmuch as they are almost 
always an accompaniment of renal calculi.* 

These forms occur only in strongly acid urine. If 

* Ultzmann, " Ueber Ilarnsteinbildung," in "Wiener Klinik," 1875, 5, 
Heft. 



TEE URINE. 155 

the acid urine is neutralized by the internal administra- 
tion of fixed alkalies, the forms of the crystals are 
changed, the pointed forms becoming the normal whet- 
stone-shaped crystals. 

The rough and pointed forms of the crystals occur 
in the urine sediment of pyelitis calculosa, and are fre- 
quently accompanied by albuminuria (hypersemia of the 
kidney) and hsernaturia. We also find these forms pres- 
ent without pyelitis or albuminuria. When this is the 
case, micturition is sometimes painful. In every case 
the uric acid is colored light yellow, brown-red, or dark 
brown by the accompanying coloring matters. 

The crystals are generally formed so large that they 
appear on the bottom of the vessel as a glistening brick- 
red sand, which may often be seen by the unaided eye. 

This sediment dissolves on heating with caustic 
alkali ; partly because some urates are formed, while 
the remainder of the acid is deoxidized. The sediment 
gives finally a beautiful murexide reaction. 

4. Calcium Oxalate. 

Oxalic acid has a strong afiinity for calcium. Since 
calcium salts are present in the urine, the oxalic acid 
which is excreted by the kidney or forms in the urine 
is observed in combination as calcium oxalate. These 
crystals result, as already mentioned, from the acid fer- 
mentation together with uric acid. The shape of the 
calcium oxalate is very characteristic. The crystals are 
generally quadrilateral octahedrons which have a strong 
refractive power. Sometimes they appear as small but 



156 ANALYSIS OF THE URINE. 

distinctly angular dots, and sometimes as rectangular 
plates whose angles are joined by diagonal lines, causing 
the envelope appearance. Some appear oblique. Be- 
sides these principal forms, we sometimes observe dumb- 
bell crystals. (PL III., A.) As these crystals have a 
low specific gravity, they appear only after a long time 
in the sediment — from twelve to twenty-four hours ; 
after this time has elapsed we must carefully decant 
and look for the small four-cornered dots. 

The characteristic form of the crystals admits of no 
confusion. The only crystals with which they may be 
confounded are the triple phosphate. In the first 
place, however, the calcium-oxalate crystals are never as 
large. Secondly, calcium oxalate occurs in acid urine, 
triple phosphate appears in neutral or alkaline. Final- 
ly, acetic acid dissolves the triple phosphates, but has 
no action on the calcium oxalate. 

5. Cystine. 

Cystine forms regular hexagonal tables of varying 
size. These occur singly, or we find a large plate at 
the bottom, and smaller and smaller plates as the series 
ascends; we also observe a shingle-like series. Some- 
times a large crystal breaks, showing the hexagonal 
cleavage to be still preserved. Small, imperfectly devel- 
oped crystals form irregular lumps. Often the corners 
of the plates are rounded as if melted off. The crystals 
are always colorless. (PI. VI., A.) These crystals can 
only be confounded with a pure, colorless, rarely occur- 
ring form of uric acid. This similarity is observed when 



TEE URINE, 157 

the cystine is precipitated by acetic acid ; for, when uric 
acid is precipitated in the same manner, the forms are 
similar six-sided plates, but generally not as regular. 

In order to ascertain if our crystals under the micro- 
scope are cystine, we carefully allow a drop of ammonia 
to flow under the cover-glass. Instantly the crystals of 
cystine vanish, while uric acid without the application 
of heat remains unchanged. As soon as the ammonia 
has evaporated, the cystine again crystallizes. The re- 
precipitation is assisted if we add a drop of acetic acid 
to the ammoniacal solution. 

A second test consists in treating the cystine crystals 
with a drop of hydrochloric or oxalic acid. Cystine 
dissolves, while the uric acid will remain unchanged. 

The form of the crystals and their insolubility in 
boiling water prevent cystine from being confounded 
with the urates. 

Cystine is soluble in ammonia, but insoluble in car- 
bonate of ammonia. In case the cystine is held in solu- 
tion in the acid urine at the beginning of the alkaline 
fermentation, it is precipitated like an earthy phosphate 
by the carbonate of ammonia generated. 

From the earthy phosphates and triple phosphate 
cystine is easily distinguished by chemical tests, and by 
the microscope, which shows the earthy phosphates as 
an amorphous powder, while the triple phosphate pre- 
sents an entirely different form of crystals. 

Acetic acid dissolves the earthy phosphates, but the 
cystine is unaltered by it. But, if it happens that by 
addition of acetic acid and heat the greater part of the 



158 ANALYSIS OF THE URINE. 

sediment dissolves and but a trace remains, this should 
be brought under the microscope ; and, if hexagonal 
plates appear, they should be treated in the above de- 
scribed manner with ammonia and hydrochloric acid, to 
distinguish the cystine from uric acid. 

If we dissolve cystine in KOH, w^arrn, add water, 
and then a solution of nitro - prusside of sodium 
(Na 2 (CN) 5 (NO)Fe // ), the mixture becomes violet. This 
reaction also will show albumen or any other compound 
containing sulphur in the dyad form. 

The urine in which we find cystine is mostly pale. 
When putrefying it develops, besides the ammoniacal 
odor, that of hydrogen sulphide, which in all proba- 
bility occurs as a decomposition product of the cys- 
tine. The sediment of cystine occurs in connection 
with cystine stone, and also independently of it. It 
appears white or dirty yellowish-gray, often with an 
abundance of triple phosphate and phosphate of cal- 
cium ; in acid urine, with calcium oxalate. 

This sediment seldom occurs with us, but it some- 
times happens that many members of a family suffer 
from cystinuria. 

6. Leucine cmd Tyrosine. 

Both of these substances are usually found together 
in the urine, but mostly in solution. Simple evapora- 
tion serves to produce a sediment (p. 124). Tyrosine 
sometimes appears as a sediment without this treatment. 

Under the microscope leucine appears as spheres of 
various sizes, more or less colored, and having the ap- 



THE URIXE. 159 

pearance of large drops of fat. They are sharply 
defined, and show in a favorable light fine radiating 
stripes and also delicate concentric lines. 

Tyrosine forms very fine short needles, made up 
into sheaves or bundles crossing each other at various 
angles. (PI. IV., A.) 

Sometimes leucine spheres are distributed through- 
out this formation. The addition of a drop of ether 
will prevent confusion of the leucine with fat-globules, 
for fat is dissolved by the ether. The crystals are solu- 
ble in caustic alkalies, but not in cold mineral acids. 

Tyrosine crystals can be identified in two ways, by 
Piria's and Hofmann's tests. The first method consists 
in placing a small amount of the sediment in a watch- 
glass, and moistening with a few drops of concentrated 
sulphuric acid ; after an interval of twenty to thirty 
minutes add some water and neutralize the solution with 
calcium carbonate as long as it effervesces, and then fil- 
ter. If, on the addition of ferric chloride which is free 
from acid, a violet color is produced, tyrosine is present. 

The second method is still simpler. The sediment is 
diluted with water and boiled ; to the boiling fluid add 
a few drops of mercuric-nitrate solution. If a red pre- 
cipitate falls and the supernatant fluid is rose- or pur- 
ple-red, tyrosine is present. Leucine and tyrosine occur 
in the urine very infrequently, seldom otherwise than 
with acute yellow atrophy of the liver and phosphorus- 
poisoning. 

7. Fat. 

The fat-globules which float on the surface of many 



160 ANALYSIS OF TEE URINE. 

urines must not be regarded as coming from the urinary 
organs. We often find that the patient has been cathe- 
terized, and the fat has come from the oil used to lubri- 
cate the catheter. We must also be careful regarding 
the finely divided fat-globules under the microscope ; 
they are apt to be from unclean object-glasses, or 
from the urine having been collected in greasy bottles 
which have previously contained hair oil or some fatty 
emulsion, medicines, etc., or to be caused by milk 
having been emptied into the vessels used for the 
urine. 

The assertions that entire fat-globules appear in 
the urine with excessive fatty degeneration of the kid- 
ney, we are unable to confirm by our personal observa- 
tion.* An emulsion of fat is observed in the chylous 
urine of the tropics (galacturia), partly causing its tur- 
bidity. The turbidity from these causes is cleared up 
by shaking with ether. In such urine the sediment is 
peculiar ; as the specific gravity of the urine is higher, 
the sediment will rise to the surface as a cream. The 
fat shows under the microscope various large spheres 
with sharp contours. Ether dissolves it. Cholesterine 
occurs sometimes along with the fat, but very rarely, 
and for the most part in a crystalline form, recognized 
by the clear, large rhombic plates. In Europe galactu- 
ria occurs very seldom. 

[* Dr. Tyson claims to have observed the fat-globules referred to in the 
text. Dr. Roberta observed free oil after the exhibition ot' cod liver oil, 
and Dr. Henderson in three cases of heart-disease. Dr. Cushing found 
considerable quantities of pure oil in the urine of a case of left lumbar 
abscess opening into the ureter.] 



TEE URWE. 161 

[In England there have been several cases of chy- 
luria reported,* some of which occurred in persons who 
had never been out of the country; and in some of 
them the urine at times seemed rather lymphous than 
chylous (i. e., the fat is absent, but albumen and fibrine 
remain — the milky appearance being absent, but the 
capability of forming a clot spontaneously also remain- 
ing [fibrinuria]). The pathology of these cases is ob- 
scure. In chyluria, as observed in the tropics, where it 
is endemic, the symptoms may be of a very slight na- 
ture, with an intermittent character to the disease, and 
the patient's general health may suffer very little, or, 
there may be severe symptoms, such as renal colic or 
strangury, and the long-continued drain on the system 
may produce exhaustion and pave the way for grave 
intercurrent disease. In the urine of persons contract- 
ing the disease in the tropics, the filaria sanguinis hom- 
inis is so often found as to suggest a causal relation 
between it and the affection.] 

8. Earthy Phosphates. 

a. Amorphous. — In ammoniacal urine we find regu- 
larly a heavy precipitate of grayish-white sediment, 
which the beginner often mistakes for pus. This sedi- 
ment is the precipitated earthy phosphates, i. e., calcium 
and magnesium phosphates. As we have said, these 
salts are only soluble in acid fluids, and consequently 
must have been precipitated from the time when the 

[* Koberts {op. cit., p. 335 et seq.).] 
11 



162 ANALYSIS OF TEE URINE. 

urea changed to carbonate of ammonium, thereby ren- 
dering the urine alkaline. Under the microscope the 
earthy phosphates appear as granules of various sizes, 
which do not f omi the mossy groupings that characterize 
the urates. Their identification chemically is very easy. 
The urates, with the exception of urate of ammonium, 
occur in acid urines, while the earthy phosphates (the 
crystalline calcium phosphate which occurs in acid urine 
being excepted) are found only in alkaline urine. The 
reaction with litmus settles the question as to whether 
we have to do with urates or phosphates. By heating, 
the urates disappear while the sediment of the phos- 
phates increases. By addition of KOH or Na OH the 
urates dissolve, while the phosphates remain unchanged. 

The distinction between phosphates and pus is shown 
in Donne's test. (P. 171.) 

All circumstances which lead to alkaline fermenta- 
tion of the urine, or cause the alkalinity of the same, 
tend to the formation of the sediment described, which 
is precipitated in mass proportional to the amount of the 
earthy phosphates in solution. 

Only exceptionally, with bladder catarrh or after the 
use of a great amount of alkalies, is the urine alkaline 
upon evacuation. In these cases it is already turbid 
from the precipitation of the earthy phosphates thrown 
down in the bladder. Generally the turbidity appears 
only a shorter or longer time after evacuation of the 
urine. These amorphous earthy phosphates are often 
mixed with a beautiful combination of magnesium phos- 
phate with ammonium — the so-called triple phosphate. 



THE URINE. 163 

b. Crystallized calcium phosphate. — Crystalline cal- 
cium phosphate, of the formula P0 4 HCa + 2H 2 0, is 
found in pale weakly acid urines, which have a tendency 
toward alkaline fermentation. 

This sediment appears with some persons as an 
individual peculiarity oftener than from other causes. 
We have observed individuals living under healthy 
normal conditions to have in summer a daily sediment 
of crystalline calcium phosphate in the urine. 

Under the microscope the crystals appear club- 
shaped, with broad oblique bases. They may be iso- 
lated, or may lie over one another, the points converging 
together, often forming a rosette, the periphery being 
formed by the bases of the crystals. 

In some cases the crystals do not simply form cir- 
cles, but make up segments of spheres. (PI. III., B.) 
(Other forms are described in K. B Hofmann's " Zoo- 
chemie.") 

The forms of the crystals are so characteristic that 
confusion is hardly possible. The triple phosphates 
which may accompany them in later stages of alkaline 
fermentation have no points, and moreover form no 
bouquets or rosettes. 

From uric acid this sediment may be distinguished 
by the fact that it is colorless and disappears on addi- 
tion of acetic acid. 

9. Magnesium Phosphate. 

In neutral or weakly alkaline urines, which we ob- 
serve after the internal use of the fixed alkali carbonates 



104 ANALYSIS OF TEE URINE. 

or mineral waters containing them, appear long quadri- 
lateral tables of basic magnesium phosphate, Mgg(POA 

-J-17BLO. two opposite angles of which have been 
truncated. If we allow a drop of a solution of eoinmer^ 
eial auimonimn carbonate, in live parts of water, to flow 

over these crystals beneath the cover-glass, they become 
opaque, and appeal' like rough leather gnawed on the 
edges. 

Calcium phosphate does not become opaque, and is 
more slowly affected by such treatment. Triple phos- 
phates are not altered. 

This sediment is very rare, and can only develop in 
urine which is strongly concentrated and is originally 
neutral or alkaline. If the urine becomes alkaline from 
the urea decomposition, there is naturally no magnesium 
phosphate, but we have ammonio-magnesium phos- 
phate. 

10. Triple PhosphaU 

These appear as large, clear, refracting crystals, with 
distinct smooth surfaces and sharp edges. Among the 
many combinations of the rhombic and very frequently 
partially ainorph»u> shapes, the coffin-lid crystals are 
the most common. (PL III., B.) They might be con- 

nly with sodium chl< r calcium oxalate; 

but sodium chloride only a}'] ystals in evapo- 

rated urine. From calcium oxalate they may be distin 
I by adding a cb 

-. it i- triple phosphates; if it remains un- 
changed, it is calcium oxalal udkionfl w 



TEE URINE. 165 

which these occur have been spoken of under earthy 
phosphates. 

11. Calcium Carbonate. 

The urine of most herbivora is already cloudy when 
evacuated. The turbidity arises from the mass of the 
excreted calcium carbonate. Only exceptionally is such 
a condition found in man, though it sometimes occurs a 
short time after the urine is evacuated. The causes of 
this are somewhat obscure. 

This sediment does not come down by itself, but in 
connection with the earthy phosphates, forming a more 
or less fine grained powder, and sometimes dumb-bell 
crystals. (PL VI., B.) We can recognize this precipi- 
tate by its solubility with effervescence on addition of 
mineral acids. This may be observed under the micro- 
scope. If, by placing a thread or a hair under the cover- 
glass, we allow a drop of HC1 to reach the sediment, then 
we see gas bubbles of carbonic acid developed. This 
reaction is never observed with pure earthy phosphates. 
The sediment must be previously washed carefully with 
water on a filter to remove any ammonium carbonate 
(which with acids would also cause effervescence). 

Organized Sediment. 

1. Mucus. 

Considerable mucus may be contained in the urine 
and not be noticed, because of its transparency, and the 
slight difference of its refractive power from that of the 



166 ANALYSIS OF THE URINE. 

urine. Only after long standing, when the urates begin 
to come down, when the mine contains more epithelium 
than usual, or when there is a rapid and considerable 
development of bacteria, does the mucus form the before- 
mentioned nubecula. 

If these conditions are not fulfilled, we color the 
mine. 

If there is no albumen in the mine, we precipitate 
the mucus with alcohol to which some tincture of iodine 
has been added, as a stringy mass. Or the mucus may 
be precipitated by acetic acid to which has been added 
a little of a solution of iodine dissolved in potassium 
iodide. The acetic acid causes a turbidity of the mucine 
in solution, which is not affected by an excess of this 
acid, but which vanishes upon addition of a couple of 
drops of HC1. 

If the turbidity of the mine disappears by applica- 
tion of heat, we know it was not due to mucus, but to 
the urates. Mucus has no characteristic form under the 
microscope ; we find only crystals of oxalate of lime and 
uric acid, as well as mucus-corpuscles (young cells) or 
bladder epithelium which have been held in suspension 
by the mucus. 

Mucus coagulated by acetic acid, however, shows 
under the microscope a granulated mass, for the most 
part striated bundles, sometimes simulating casts and 
cylinders. 

In women we generally find a much greater nube- 
cula, because the urine is usually mixed with a great 
quantity of vaginal mucus, especially with fluor albus. 



THE URINE. 167 

Since mucine only swells in water and undergoes no 
real solution, we may separate it from the urine by 
filtration. The mucus remains on the filter, and appears 
there when dry as a glistening varnish. Urines contain- 
ing much mucus filter badly, for the reason that the 
pores of the paper are stopped. 

2. Epithelium. 

We have already mentioned the young cells as 
mucus-corpuscles. Other cells appear in the urine 
which serve as an epithelial covering for the mucous 
membrane of the urinary apparatus, or as the proper 
glandular tissue of the kidneys. 

Manifold as the forms of the epithelial cells appear, 
if we examine the various parts of the urinary apparatus, 
we do not find all these forms represented in the urine. 
The urine, as a fluid containing various salts in solution, 
works a change upon the epithelial cells. Three forms 
may with certainty be distinguished : 1. Kound cells ; 
2. Conical and caudate cells ; 3. Flat cells. 

1. The round cells arise from the tubules of the kid- 
ney, and from the deeper layers of the mucous mem- 
brane of the kidney-pelvis. In their original form they 
are more or less oppositely flattened, corresponding to 
their position beside one another. (PL I., A, 1.) Un- 
der the influence of the urine they swell and become 
globular. They have a clearly defined nucleus, and are 
by this easily distinguished from the pus -corpuscles 
which also appear in the sediment. The pus-cells are 



168 ANALYSIS OF THE URINE. 

uniformly granulated, and show their nuclei with dis- 
tinctness upon addition of acetic acid. The epithelial 
cells contain but one nucleus, the pus-cells two, three, 
and sometimes more ; "besides, the epithelial cells are 
larger. 

In acid urine the epithelial cells are preserved a 
long time, but if the urine is neutral or alkaline they 
appear greatly swollen, nearly hyaline, the granular 
protoplasm entirely surrounding the nucleus ; after a 
time they become wholly dissolved. The epithelium 
of the male urethra is very similar to the kidney epi- 
thelium, so that it is difficult to distinguish one from 
the other under the microscope. (PI. I., B, 1.) The 
distinction is usually based upon the chemical constitu- 
tion of the urine. If the urine contains albumen, the 
round cells are due to a desquamation from the urinary 
tubules. If albumen is not present, the round cells 
are probably from the urethra. 

The epithelium of the prostate, Cowper's, and Lit- 
tre's glands is similar to that of the urethra, and can 
not be distinguished from it microscopically. With 
mucus and pus the epithelium forms the so-called gonor- 
rhoea! threads. (PL VI., A, 2.) 

2. The conical and caudate cells have their origin in 
most cases in the pelvis of the kidney. Very delicate 
cylindrical cells come also from the accessory organs of 
the male urinary apparatus, though they are of rare 
occurrence. The cells are generally twice as long as 
broad, and arc -mailer at one end than at the other. 
The caudate cells may have a prolongation on one end 



THE URINE. 



169 



(unipolar), or they may have spindle-shaped prolonga- 
tions on both (bipolar caudate cells). (PL I., A, 2.) 
The presence of these cells must not be regarded as an 
indication of a neoplastic growth, as is stated in the 
older writings. 

3. The fiat cells arise either from the bladder or 
the vagina. They are most irregular, polygonal with 
rounded corners, and have a sharply defined dark 
nucleus nearly in the centre. This nucleus bulges out, 
as may be seen when the cell is standing on its edge, 
making the cross-section appear like a spindle-cell. (PL 
L, B, 2.) 

It is difficult sometimes to distinguish the bladder 
epithelium from that of the vagina. The bladder 
epithelium is more delicately formed, and generally 
appears singly ; the epithelium of the vagina is some- 
what coarser, has sometimes a warped surface, and is 
almost always cast off in great cohering shreds ; fre- 
quently the scales are arranged in layers, an appearance 
never occurring in bladder epithelium. (PL I., B, 4.) 

The yellow color of the nuclei of various epithelial 
cells with icterus is interesting. If we now allow a 
drop of fuming nitric acid to now under the glass cover, 
we observe the nuclei to pass through the color changes 
of Gmelin's test (green, blue, violet, etc.) (Ultzmann). 



3. Pus-corpuscles. 

The pus-corpuscles of the urine are quite similar in 
appearance to those of a suppurating wound. They are 



170 ANALYSIS OF THE URINE. 

round cells twice as large as blood-corpuscles, with a 
uniformly granular exterior which surrounds the nuclei. 
The nuclei may be exhibited more distinctly by the 
addition of a drop of acetic acid under the cover-glass : 
the granulation vanishes, the corpuscle swells, and the 
several centrally placed nuclei become visible. Besides 
this usual form, there is another of rare occurrence, in 
which the corpuscles are not round, but have various 
prolongations which show amoeboid movement. (PL 
VII., B.) 

The pus-corpuscles are changed, especially in ammo- 
niacal urine, under the influence of carbonate of ammo- 
nium. They swell up and coalesce, showing under the 
microscope a homogeneous mass, in which the nuclei 
alone are distinguishable. Such pus forms a vitreous, 
slimy mass, which on pouring flows out as a whole, like 
albumen when poured from one vessel to another. 

This must be distinctly emphasized, lest the beginner 
fall into error in supposing that such a slimy mass is 
mucus or albumen. The latter does not form a sediment 
under any conditions, and mucus never forms a like 
cohering mass. If pus is in the urine, pus-seruni and 
albumen must also be present. We may always obtain 
the albumen-test, which is not the case with mucus. 

The amount of pus-corpuscles is various. Often the 
urine contains so few that they (forming no sediment) 
escape the unaided eye. In some urines so much pus is 
present that a sediment several fingers high is formed of 
a yellowish or grayish white color. 

A confusion with the urates is possible in acid 



THE URINE. 



171 



urines, and with the phosphates in alkaline. We have 
already described the tests for the urates. The phos- 
phates disappear on addition of a few drops of acetic 
acid ; pus does not. 

Donne's test permits the distinction without the aid 
of the microscope. Pour the urine from the sediment, 
and add a little piece of caustic soda or potassa. If the 
sediment consist of pus, then it will lose its white color, 
becoming greenish and vitreous, first stringy, then 
thicker, until finally it forms a cohesive lump. It has 
in this manner taken on the appearance of pus in a 
strongly alkaline urine. Since no other body in the 
urine can give this reaction, it is a perfectly safe method 
of distinguishing pus. If the amount of pus is scanty, 
one can not expect to obtain the cohesive lump, but on 
the contrary the sediment disappears and the fluid be- 
comes vitreous and stringy. 

With the sediment are mixed broken-down pus-cor- 
puscles (detritus), and frequently blood-corpuscles, epi- 
thelial cells, etc. 

4. Blood- Corpuscles. 

Blood-corpuscles in the urine may be distinctly rec- 
ognized when present in but small amount. If the 
urine is tinged a brownish red, and the suspicion arises 
that blood-coloring matters or corpuscles are mixed with 
it, we allow it to stand for some time, in order that the 
light and sparingly present blood-corpuscles may form a 
sediment (often but a trace), which is colored a beauti- 
ful red. 



172 A XA LYSIS OF THE URINE. 

In acid urine the blood-corpuscles retain their char- 
acteristic form for a long time. They exhibit small 
disks, which show a central shadow corresponding to 
the depression. If the blood-corpuscles stand on their 
edges, they appear biconcave. They are always single 
(except in profuse haemorrhages from the bladder, when 
they form rouleaux), and appear reddish with a slight 
greenish tinge. 

This original form of the blood-corpuscle undergoes 
many changes, brought about by the nature of the men- 
struum in which the corpuscles are distributed. If the 
urine is very dilute, especially if it has began to be am- 
moniaeal. the corpuscles swell, the depression disappears. 
and they become spherical, appearing somewhat smaller 
than before. The central shadow vanishes with the 
and instead the corpuscle has a peripheral 
shadow by which it is recognized as a sphere. 

By longer exposure to the above influences, the cor- 
puscle becomes more indistinct and appears as a delicate 
bubble, which then becomes bat a mere shadow in the 
field, finally disappearing. 

By treatment with a neutral-salt solution the blood- 
•me smaller and j These ;'. 

forr rved in the urine, often in connection with 

the normal. The appear to have produced 

within tl 11 crystals whose ends cause the 

limiting membrane to become distorted (PL V.. A. 2.) 

■ not r<»und but oral, and 
- in the same orix up- 

sha] 



THE URINE. 



173 



In hsematuria which accompanies parenchymatous 
affections of the kidney and bladder, we find almost 
always spherical corpuscles of different sizes. Quite 
small, even dust-like blood-corpuscles (microcytes) occur 
in such cases with normal and greater forms (macro- 
cytes). 

No matter how small an amount of blood-corpuscles 
is present, it is always possible to prove the presence of 
albumen in connection. 

If the blood-corpuscles have been dissolved in an 
ammoniacal urine, we may test for the coloring matters 
(haemo- or methaamo-globine), as described on page 128. 

Eegarding the origin of blood-corpuscles in the urine, 
the subject is treated of in Chapter VIII. 



5. Cylinders. 

The identification of cylinders plays a most impor- 
tant part in the diagnosis of kidney diseases; for by 
their form they betray their place of origin in the urin- 
ary tubules. In the investigation of the urine, the 
greatest care must be taken that these be not over- 
looked. By their low specific gravity they remain for a 
long time suspended in the urine. To this may be 
added the circumstance that their appearance is gener- 
ally accompanied with albuminuria, and in the albu- 
minous fluid their precipitation is very slow. 

The precautions necessary for the investigation of 
these forms are as follows : The urine must be permit- 
ted to stand for several hours, then carefully decanted, 



174 ALYSI8 OF THE UEIXE. 

and the residue shaken up in a pointed sediment-g] 

and allowed to stand again one or two hours. The last 
drop- of the sediment should be brought under the 
mia One should never be satisfied by one ex- 

amination, as the number of cylinder- is always small 
and may ; verlooked on hasty investigation. TTkile. 
on the one hand, we must exercise caution not to over- 
look the cylinders, on the other hand we must not mis- 
take for them materials of an entirely different nature. 
Beginners are apt to see granular cylinders in every 
accidental cylindrical arrangement of the phosphates or 
urates, especially if imbedded in stripes of mucus. 

Although cylinders are generally accompanied by 
albuminuria, there is albuniinmia with which no cylin- 
ders are found, and there are isolated cases in which 
cylinders are present without contemporaneous albu- 
minuria. Examples of the first case are the albuminuria 
of interstitial nephritis, of amyloid kidney, and renal 
stasia : as an example of the second condition, severe 
inflammatory processes are to be mentioned, in which 
the cylinders precede albuminuria from twelve to twen- 
ty-four hours 

Amoncr the numerous cylinders the chief forms 
(partly passing into one another) are the following: 
1. Tl^ ordinary fibrine cylinder : 2. The fine granulated 
cylinder; 3. The hyaline cylinder; 4. The waxy cylin- 
der: 5. The epithelial and cylinders; 6. Tin- - - 
called uric acid cylinder ; 7. T teriaandmic 
cyl i 

1. The ordinary fibrine-cylmders are roll-formed, 



THE URINE. 175 

often spirally twisted clots, with a sharp contour and of 
a light yellow to brown-yellow color. Their calibre 
exceeds that of the other casts, so that they may be 
regarded as having their origin in Bellini's tubes (see 
Fig. 2), near their outlet upon the papilla ; frequently 
the epithelial cells adhere to them. The blood-cylinders 
may be regarded as a lower form of the fibrine-cylinder ; 
these consist of clotted blood, and arise from rupture of 
the glomeruli. These are always dark brown, and ap- 
pear to consist of a compressed clot of blood-cells. 
Sometimes we observe on one part of a cylinder a 
fibrine-clot, while the other is covered with blood- 
corpuscles. This form is always accompanied with 
isolated blood-corpuscles in the sediment. (PI. VII., 
A,l.) 

2. The fine darhgranuled cylinders are smaller than 
those described above. They appear under the micro- 
scope as a solid plug from the more remote urinary 
tubules. They have sharp contours, and appear, as 
their name implies, finely granulated throughout ; they 
are rounded off on one or both ends like a finger, ap- 
pearing uniformly of the same calibre, or constricted as 
if strangulated. They may be shaped at one end like 
the neck of a bottle. In the granulations many modifi- 
cations are to be observed : in some places the granules 
are coarse, and in others the casts seem to have almost 
lost their granulations and to have become hyaline. 
Sometimes fat-globules are mixed with the granulations. 
Upon the addition of acetic acid, in some cases the 
granulations disappear, so that the cylinder becomes 



176 ANALYSIS OF THE URINE. 

clear; in other cases this has no influence whatever. 
The color of the granulated cylinders is a pale, dirty 
grayish yellow. (PL VII., A, 2.) 

Both these forms of casts remain a long time un- 
changed in acid urine, while in alkaline they gradually 
become more indistinct and finally disappear. 

3. The hyaline cylinders are of the same size as the 
granular casts, or they may be smaller. They are some- 
times straight and sometimes curved ; the length is 
often considerable. While at times the appearance of a 
solid body is unmistakable, again they appear as very 
delicate tubes cylindrically formed, sometimes ribbon- 
shaped. Frequently we find spirally twisted cylinders, 
with one or more turns. (PI. VII., A, 3.) In the first 
and greater forms a distinct contour is visible, while the 
last mentioned forms are difficult to recognize from the 
surrounding medium, and under the microscope they 
only appear as a shadow. In such cases it is advisable, 
in order to bring out their form, to add a drop of iodine 
dissolved in potassium iodide solution, or aniline violet, 
by means of which the cylinders appear respectively 
yellow or blue-violet, and may be better distinguished 
from the paler surroundings. They show generally no 
trace of granulation, but are perfectly transparent. 
From the narrowness of the ribbon cylinders, they are 
supposed to come from the smaller branches of the 
urinary canals, perhaps from the fine ascending loops of 
Henle. The hyaline cylinders disappear soon in alkaline 
mine. 

4. The waxy cylinders are about the width of the 



THE UBHTR 177 

granular, perfectly clear and strongly refractive, so that 
their contour is as sharply defined as the triple phos- 
phates or similar clear crystals. They are straight, 
broken, or curved. Their surface is often wavy, as if 
they were made up of coalescent colloidal nodules. In 
places they show deep indentations, as if the gelatinous 
mass had yielded to pressure. They give the amyloid 
reaction, and are tougher than the other cylinders. This 
form of cylinder is of rare occurrence, and has been 
found only with amyloid degeneration and tuberculosis 
of the kidney. (PL VII, A, 4.) 

5. The epithelial easts and cylinders are processes by 
which the epithelial coating of the urinary canals is 
stripped as a whole from the membrana propria, and by 
the vis a tergo of the urine or of a fluid exudation is 
forced out of the tubule. These forms, which are made 
up of epithelial cells and have a lumen, we term epithe- 
lial tubular casts. With these, in the same sediment, 
we find cylinders made up of hyaline substance covered 
with epithelial cells. We may find the latter without 
the former. (PL YIL, A, 5.) 

The epithelial cells appear cloudy, are somewhat 
swollen, and show very seldom a sharply defined sepa- 
rating border. Often their swelling has so far advanced 
that they appear more like a homogeneous finely granu- 
lated mass, in which the nuclei alone, separated from 
each other by regular distances, allow them to be recog- 
nized as epithelial cells. 

Among the epithelial cylinders there are some in 
which the coagulated interior bulges through the cover- 

12 



178 ANALYSIS OF THE URINE. 

ing of epithelium ; in others the central exudate projects 
at the ends. 

6. The uri&acid cylinders are distinguished by their 

characteristic composition, and they are only enumerated 
with the other on account of their form and place of ori- 
gin. The uric-acid cylinders occur in the urine of nurs- 
lings who suffer from uric-acid infarction of the kidney. 
Aa in the urine, so also in the wash of the child we 
observe small red forms, which under the microscope 
are recognized as cylinders, made up of small granules 
of the urates, and not, as their name would denote, of 
pure uric acid. They are brown-red, show distinctly a 
coarsely granulated structure, and vary greatly as to 
size. (PL YIL, A, 6.) If treated with KOH, ammonia 
is set free and the cylinders disappear. Besides the 
perfect cylinders, we find fragments. 

7. Oylmders of bacteria and micrococci appear only 
with interstitial suppurative nephritis, and here also 
only in those cases where the disease is complicated 
with bacterian embolism of the urinary canals (nephritig 
parasitica, Klebs). We find these cylinders of the shape 
and size of the firm fibrine cylinders. They arise from 
the same place, the tubules of Bellini. We often find 
these forked, when they correspond to the junction of 
two straight tubes. They consist throughout of bac- 
teria and micrococci. Since the bacteria are in a state of 
rest, these cylinders resemble the coarse-grained granular 
cylinders ; these latter, however, are much smaller and 
more delicate. By applying a high power of the micro- 
scope, confusion ia not easily possible. 



THE URINE. 179 

Under the above-mentioned forms the reader will 
miss some which have been described in other books, 
but which we ourselves have had no opportunity of 
observing ; and we conclude that, if such forms do occur, 
it is only very rarely. The cylinders of pus-cells must 
not be confounded with the short plugs of purulent 
matter which arise from the papillary part of the kid- 
ney and are characteristic of chronic pyelitis. Further, 
we mention cylinders of calcium oxalate and also cyl- 
inders with imbedded uric-acid crystals. It often hap- 
pens that to the cylinders crystals of uric acid and 
oxalate of calcium become attached. They do not ap- 
pear imbedded in the cylinder mass, but added after it 
has left the urinary tubules as an accidental attachment. 

6. Fivngi. 

In the urine a number of parasitical growths may 
exist, some of which are of frequent occurrence, while 
others appear more accidentally. 

The most frequent forms which one has the oppor- 
tunity of observing are the following: 1. Bacteria; 
2. Yeast fungi ; 3. Sarcinae ; 4. OTdium lactis ; 5. Dif- 
ferently developed spores and fragments of jpenicillium 
glaucum. Some forms occur oftener in alkaline and 
others in acid urine. 

1. Bacteria, predominantly inhabitants of alkaline 
urine, described by some authors as a low form of ani- 
mal life, by others as a plant, being spoken of synony- 
mously as Vibriones, Monades crepusculce, MicrozymoB, 



180 ANALYSIS OF TEE URINE. 

etc. At present it appears probable that they belong 
to the fungi and are grouped under Nageli's Schyzomy- 
cetes. They are very different in their appearance, and 
from a practical standpoint, according to A. Vogel, they 
have received various names. It is only necessary to 
remember that they are fungi. 

A urine which contains an appreciable amount of 
bacteria appears always cloudy. After a long time part 
falls as a sediment to the bottom without the fluid be- 
coming clear. According to A. Vogel, the following 
forms are to be distinguished : 

a. The monad forms. These are round punctif orm 
bacteria, which either remain quiet or show a quivering 
motion. One must exercise care not to confound with 
these the earthy phosphates which have a molecular 
movement. While the movement of a dead organism 
goes on in one place, the monad forms of bacteria 
change their position in the field. 

b. The rod forms. These are very small rods, 
scarcely the diameter of a blood-corpuscle, and im- 
measurable in thickness. Both ends are generally 
swollen and knob-formed. They are sometimes at rest 
and sometimes moving through the field. 

c. The vibriones. These are made up of the above- 
mentioned forms — two or more rod-like bacteria hanging 
on to one another, moving sometimes spirally and some- 
times with a motion resembling that of a fish's tail, 
going hither and thither with great rapidity. 

d. Leptothrix, or chain forms. These are long, 
often reaching across the entire field, and are to be dis- 



THE URINE. 181 

tinguished only by their length from the vibriones. 
Only with a very high magnifying power can their 
jointed composition be recognized. They move but 
seldom, and then very sluggishly, in the manner of a 
serpent. 

e. The zoogloa forms. These appear as masses of 
punctif orm bacteria held together in a common gelatin- 
ous mass, resembling a precipitate of earthy phosphates 
held in mucus. 

All these forms may be observed in the same urine, 
and often under the same cover-glass. 

2. The yeast plants {Saccharomyces urince). — These 
are single vesicular cells, of the size of blood-corpuscles, 
and of somewhat oval shape. Usually, however, they 
are made up of small cells arranged like a rosary, some 
of the beads having two or three bud-like cells attached. 
(PL VIII., A, 1.) This fungus appears in much less 
quantity than the bacteria, and is found mostly in acid 
urine on a warm day. This plant has the greatest simi- 
larity to the yeast plant of beer (Saccharomyces cere- 
visice), without being identical. In diabetic urine this 
form occurs, but more vigorously developed. 

3. Sarcinw. — This form has the greatest similarity 
to Sarcina ventriculi, but is appreciably smaller. They 
are arranged in groups of 2, 4, 8, etc., and the small 
cells are built up in cube form and present the ap- 
pearance of a cross-bound bale of goods. (PL VIII., 
A, 3.) 

The urine in which sareinae are found is chiefly al- 
kaline, and in the sediment we find also calcium- and 



[82 AXALTSIS OF THE URIXE. 

triple phosphate. The evacuation of sarcinae lasts for 
weeks, sometimes for months. 

•i. Oidium lactis. — This appears in the form of long 
cells, recognized by their granules being arranged at 
regular intervals. These occur not infrequently- in the 
fermenting mine of diabetes. 

5. PeiiiciUium glaucum. — There may exist in the 
urine also spores of this plant. In great part these 
exist as germs, often as branching forms or reticulated 
fibers, covered with a coating of fine urates, appearing 
furry and brown-red. (PL VIIL, A, 2.) 

[6. The Bacillus tuberculosis has been found in urine, 
but precaution should be taken, as a form very closely 
resembling it has been found in the healthy urethra.] 

The spores for the evolution of all the f omis of fungi 
mentioned develop outside of the bladder. This rule, 
however, has exceptions. The sarcinae are always ex- 
creted with the urine from the bladder. Sometimes 
this may be the case with bacteria, though this may be 
explained from the use of unclean sounds or catheters. 
Cases have come to our knowledge, though very rarely, 
where there was certainty of no instrument having been 
introduced previously into the bladder or urethra. It is 
very difficult to ascertain whether these forms of fungi 
have any influence on the reaction or fermentation of the 
mine. The small chain fungus appears not alone in 
alkaline urine, but in every ease in which an albuminous 
substance becomes fetid or decomposed. "We therefore 
find the same in the secretions of different ulcers, in 
ichor, and in cholera stools. 



THE URINE. 183 

In this place we may mention in passing an indica- 
tion which was formerly considered a characteristic sign 
of pregnancy. With the name kyesteine was christened 
that membrane which forms on the surface of long- 
standing urine, and which consists of an interlacing net- 
work in which calcium- and triple phosphates, bacteria, 
and sometimes also animal organisms, are imbedded. It 
forms, however, upon the urine of men, and has of late 
lost its significance. 

7. /Spermatozoa. 

Spermatozoa appear with a strong power (Hartnack, 
III., 7 = X 330) as small rounded forms, with a longer 
or shorter hair-like tail. Seldom has one an opportunity 
of seeing them in motion in the urine. A urine which 
contains spermatozoa often shows white cloudy flakes, 
which under the microscope are resolved into a mass of 
spermatozoa imbedded in a finely granulated substance. 
Since spermatozoa are very light, they require several 
hours to settle. After six to twelve hours we find, 
besides the flocculent lumps, also isolated seminal gran- 
ules. On account of the resisting capability of these 
structures, they may be found in the urine after several 
days. (PL VI., A, 3.) 

We find spermatozoa — 

1. After coition, nocturnal pollution, etc., when a 
part of the semen remains behind in the urethra, and is 
washed out later by the urine. 

2. With spermatorrhoea. 

We also observe involuntary emissions in typhus. 



184 ANALYSIS OF THE URINE. 

In the urine of women we find spermatozoa after 
coition — a fact which may have great medico-legal im- 
portance. 

8. Cancer Elements. 

Two different forms of cancer elements are observed, 
though quite seldom : a. Isolated cancer-cells ; b. Pieces 
of cancer-tissue. 

a. The cancer -cells are variously (PL VIII., B, 1) 
and often quite oddly formed. They are large and for 
the most part caudate cells, with a very large and often 
more than one nucleus. Sometimes we observe the so- 
called vacuoles. Care must be taken not to regard the 
caudate cells of epithelium which come from the kidney- 
pelvis as cancer-cells. The cancer-cells correspond to 
the epithelial covering of a cancerous growth, and gen- 
erally arise in the bladder. Only from an abundant 
appearance of these peculiar and many-formed cells can 
we with certainty recognize a malignant growth. 

b. Fragments of villous cancer (PI. VIII., B, 2) may 
occur in various forms in the urine sediment. We 
either find the same well preserved, when we are able 
to distinguish the papillary growth under the microscope 
(it seldom appears in this condition), or on the other 
hand it may be necrotic, when the diagnosis is attended 
with considerable difficulty. The well-preserved can- 
cerous tissue, under a magnifying power of 300 diame- 
ters, exhibits in its finest branches a characteristic tree- 
like formation, similar to fringe, which consists of a 
widened blood-vessel (Hohlkolben) covered with a 



THE URINE. 185 

single layer of epithelium. It is seldom that such a 
beautifully formed tree can be seen under the micro- 
scope. Usually sloughed off and much altered pieces of 
tissue only appear in the sediment, and the identification 
of these is very difficult. In the tree form the epithe- 
lium has generally undergone molecular disintegration, 
and is accompanied with bacteria; the villus itself is 
infiltrated with pus-corpuscles. In this molecular detri- 
tus, chiefly consisting of small flakes, we occasionally 
find forms which materially assist the diagnosis of vil- 
lous tumor. 

Often, if we treat the necrotic cancerous tissue with 
glycerine, and sometimes when we have not done this, 
we observe beautiful crystals of hsematoidine. They 
appear of a brown-yellow color, either in beautifully 
built small rhomboids or in small, yellow, grassy tufts. 
Such cancerous tissues, treated with fuming nitric acid 
under the microscope, show by the well-known rainbow 
play of colors the reaction of the biliary coloring mat- 
ters. Hsematoidine is recognized in old blood-extravasa- 
tions, but in the urinary sediment it is never observed 
except as isolated crystals. If, however, we find these 
crystals imbedded in necrotic tissue, then is the diagno- 
sis of old hemorrhagic and necrotic tissue assured. This 
condition has up to this time been found only with vil- 
lous tumors. Hsematoidine villus occurs only in acid 
urine. 

There is yet another sort of crystal which has also 
been observed by us only in necrotic villous tissue, 
which appears only in acid urine, and may also serve as 



186 ANALYSES OF TEE VRIXE. 

an index for the diagnosis. These are small, colorless, 
crossed, aggregated leafy crystals, in dumb-bell form, 
which sometimes take on a spherical shape. These are 
a veiy rare form of calcium oxalate. 

8 metirnes with a low magnifying power (120) we 
observe thicker and darker-colored, tube-shaped, branch- 
ing forms in necrotic flakes. These are small vessels 
which are to be seen in necrotic tissue. 

If the urine is strongly alkaline, we find the villous 
tissue so changed and incrusted with phosphates, that a 
diagnosis of it can scarcelv be made. One investigation 
of the mine in these cases is hardly sufficient for a 
diagnosis. 

9. JE/rdozoa, 

We have not up to this time had an opportunity of 
observing entozoa, or even fragments of them, in the 
mine. According to the claims of other authors, the 
hooks of echinococci occur. We have, however, observed 
single hooks, as also a fragment of the sac of the echino- 
coccus with the adhering animal forms, in the aspirated 
fluid of a kidney-tumor (PL VIII., A, 4) ; and it is pos- 
sible that by rupture of the same into the pelvis of the 
kidney the hooks might appear in the evacuated uiine. 

In the tropics hematuria caused by entozoa is ob- 
served Under this head the most important form of 
entozoa is the Digtoma Tumiatobwm or BUlarzia hcemck- 
tobia. It penetrates most probably from the intestinal 
tract into the plexus venosus prostaticus, and there lays 
ite egga These have an oval form, and on one end is 



THE URINE. 187 

to be seen a short point. They stop np the small ves- 
sels of the mucous membrane of the bladder ; then 
there arises a bladder-catarrh with haemorrhage, and 
the eggs become excreted in the urine. In the urinary 
sediment we find small flakes in such cases, in which 
under the microscope, besides numerous blood- and pus- 
corpuscles, are imbedded a great number of the eggs 
of Bilharzia hcematobia* 

[The adult parasite is a trematode. The male 
rarely exceeds one third of an inch in length, and 
is shorter and broader than the female, which is 
more filiform, and may attain to the lecgth of three 
quarters of an inch. They bear two suckers, and 
the male a long canal in its upper half, in which the 
female is partially inserted during copulation. The 
ova are about y^-g- inch long and -g^- inch broad, 
and are characterized by a spine at the anterior part 
of the capsule. It is by the appearance of these in 
the urine that the cause of the haemorrhage is to 
be diagnosticated. The cases in which it occurs in 
America seem to have contracted the disease in Afri? 
ca. Belfield f records such a case. 

The Strongylus gigas, a nematoid worm found 
in the kidney - pelvis of dogs, wolves, horses, oxen, 
and some other animals, has been very rarely found 
in the human kidney. It resembles the ascaris 
lumbricoides, but has six instead of three papillae 

* We have to thank Dr. Sachs, of Cairo, for some very beautiful prepara- 
tions of the natural sediment of endemic hematuria, 
[t "Diseases of the Urinary Organs," p. 154.] 



188 ANALYSIS OF THE URINE. 

around the mouth, and is larger, the male reaching a 
foot in length and one quarter of an inch in breadth, 
and the female a yard in length. It may occur in the 
urine through its ova, or in adult form; and when 
present in the renal passages may give rise to colic 
hematuria and pyuria.* 

The Pentastoma denticulatum, found under the 
capsule of the liver of herbivorous animals and 
man, was once found by Wagner under the capsule 
of the right kidney of a man dead from Bright's 
disease. Inasmuch as it has never been found in the 
urine in any form, it does not deserve further men- 
tion in this treatise. 

The Filaria sanguinis hominis seu Bancroft^ as 
the probable cause of tropical chyluria and some- 
times hematuria, is a matter of interest to Ameri- 
can and English physicians, since several cases of its 
importation from the tropics have been brought to 
notice. The form usually seen is the embryonic. 
The embryos are long, snake -like, transparent, and 
apparently structureless, from -^ to -^ inch in length, 
and 3^3 inch in breadth. It is slightly tapering 
at the anterior extremity, and terminates at the end 
in a filamentous projection like the lash of a whip. 
Viewed through a magnifying power of six hundred 
diameters, transverse markings may be observed, but 

[* The rliabrlites genitalis, a neraatoid, has recently been found in the 
urine of three persons. In one case (a woman) it seemed to come from 
the externa] genitalia. In the second case it seemed to be the cause of a 
paroxysmal hemoglobinuria, and in the third of an intermittent hcomaturia. 
The two latter persons were children.) 



THE URINE. 189 

no oval or anal openings. When drawn from fresh 
blood it wiggles quite actively. The embryos are 
found principally in the blood, and a few at times 
in the urine. Digestion and exercise cause its ap- 
pearance in large numbers when present. The adult 
is a nematoid worm, and, according to Manson, in- 
habits the lymphatics (the two sexes living together), 
where it causes a blocking up of the lymph- vessel, 
with consequent rupture and chyluria.] 

It is hardly necessary to give a further description 
of accidental entozoa which have been found in the 
urine, but which have no especial significance. 

Bits of feather dusters, of wood fibre, of dried plant- 
tissue, as tobacco leaf, dust, and cotton and woolen fibres, 
are found in the urine. Besides this, it is hardly neces- 
sary to advise care as to cleanliness of the cover-glasses. 



ADDENDA. 

CONCEETIONS. 

By urinary concretions we understand the hard, 
stony formations, which are sometimes made up of 
normal and at others of abnormal constituents. 

The size of these differs greatly. We find urinary 
concretions the size of the fist and larger, while some 
can only be recognized by the microscope. 

Every concrement, great or small, must allow the 
recognition of an arrangement of its molecules in layers, 



190 ANALYSIS OF THE URINE. 

and have a more or less rounded form. A single excep- 
tion to this rule is the cystine stone, which upon cross- 
section shows a crystalline leafy formation rather than 
layers. 

If we wish to determine the nature of the urine con- 
cretions, we must employ the aid of a lens or micro- 
scope. 

Often we find such small concretions of uric acid 
that with the unaided eye they may often be mistaken 
for the crystals of uric acid (the rosette). Just so with 
small concretions of calcium carbonate, which show dis- 
tinctly their laminations with a lens of 100 to 200 diam- 
eters. 

The small concretions come usually from the kidneys, 
the larger from the bladder. 

The stones are formed either of one constituent or 
of different stone-forming elements arranged in layers 
(eccentrically). The uric-acid stones consist, as a gen- 
eral rule, entirely of uric acid or its salts ; the cystine 
stone only of cystine ; while the oxalates have generally 
a kernel of uric acid and an outer phosphatic layer. 
The phosphatic stones possess uric-acid centres. 

Whether these urinary concretions are formed of but 
one or several constituents can in every case be distin- 
guished. 

The best means of determining the constituents of 
the concretionary layers is to saw the stone in two 
halves with a bow or jeweler's saw. 

The innermost layer of the cut surface is the kernel ; 
tli is is from the size of a millet-seed to that of a pea or 



THE URINE. 191 

larger, and is contrasted better with the surrounding 
matter if the next layer is of another color. 

The kernel is the most important part of every stone. 
It alone explains to us the cause which has brought 
about the formation. If we find a uric-acid kernel in a 
phosphatic stone, we know that the primary condition 
which influenced the stone formation was due to uric 
acid. If the kernel happens to be a fragment of a bou- 
gie or a foreign body in the centre of a phosphatic 
stone, we must recognize the agency of the foreign body 
in producing the stone. 

From a practical or surgical standpoint, stones are 
classified according to their chief constituents. Thus 
we distinguish stones of urates, oxalates, phosphates, 
and cystine. This classification has a practical impor- 
tance which is not to be underestimated ; for if the sur- 
geon diagnoses a stone as phosphatic, he may conclude 
that it is a case for the lithotrite ; if formed of oxalates 
or urates, he may conclude that the stone is very hard. 

There are frequently stones which exhibit three or 
more stone-forming constituents in their layers. It is 
more convenient to classify such stones in two groups, 
according to the character of their kernels. The first 
group includes such stones as are formed by the sedi- 
ment of acid urine. The second group includes those 
stones the kernels of which are formed by foreign 
bodies, by blood-coagula, or from the constituents of 
alkaline urine. 

This classification conforms precisely to what we 
have designated as primary and secondary stone forma- 



IQg AXALTSIS OF THE UBIXE. 

(ion. The primary formation is the building of a kernel 

of the sedimentary constituents of acid mine. The 
ndary formation is only an incrustation of a foreign 
body or of a kidney-stone arrested in the bladder. 

The primary stone formation occurs only in the kid- 
ney : the secondary mostly in the bladder. 

A peculiar class is formed by the so-called " nieta- 

■ hosed " stones, which consist of earthy phosphates. 
i m a quite homogeneous and very porous m 
They are always the product of a chronic suppuration 
which has lasted many years : the sediment of acid urine 
being dissolved by the alkaline pus. the earthy phos- 
phates are substituted 

The primary stone formation is as a rule caused by 
eric acid, since bladder-stones for the most part have a 
kernel of that substance. 

In the investigation bv "LTtzmann of 545 bladder- 
stones, the kernels were found to be composed as fol- 

- : 

Kernels of uric acid . . 441 = 80*92 per cent. 

" of calcium oxalate . 81 = 5'69 
earthy phosphates. 47 = 8*62 

" of cystine ... 8 = T47 " 
Fon kernels . . 18 = 3-3 " 

Analysts of tt< 

Even* large concretion must first be cut in two by 
means of a tine saw. The collected aawdust is well 

mix iM bei method 



THE URINE. 193 

below. By these methods we are enabled, by their 
characteristic reactions, to ascertain the principal con- 
stituent, and also to detect the various elements which 
compose the layers, but not to say in what order the 
layers occur. To find the arrangement of the layers, it 
is necessary to polish the smoothly sawed surface of the 
half, by rubbing for some time on a ground glass plate, 
when the different layers of the stone become distinctly 
visible. After dusting with a cloth, we may easily 
scrape as much powder from each layer by means of a 
pen-knife as will suffice for the test. In this way every 
urinary concretion may be accurately analyzed. Per- 
haps an example may be advantageously given. 

If a bladder-stone has been sawed in half, and by the 
analysis of the dust we have found that two thirds of 
the stone consists of incombustible (inorganic) and one 
third of combustible (organic) constituents ; and also if 
we have proved the presence of uric acid, oxalic acid, 
phosphoric acid, carbonic acid, calcium, magnesium, and 
ammonium ; furthermore, if we have polished the sawed 
surface of the stone, and recognize three distinctly sepa- 
rated and differently colored layers by means of the 
unaided eye, and find in the centre a kernel the size of a 
pea, which by analysis is found to consist only of uric 
acid, the dark-brown middle layer to consist only of cal- 
cium oxalate, and the outer white layer to be made up 
of the phosphates of calcium and magnesium, the com- 
plete analysis should be proceeded with as follows : 

Analysis, — Take several milligrammes of stone- 
powder and heat it carefully on a piece of platinum foil. 

13 



194 ANALYSIS OF THE URINE. 

After intense heating, observe whether the powder is 
entirely consumed, or whether a residue remains ; fur- 
ther, whether the powder is consumed with a visible 
flame, whether it decrepitates (oxalate of lime), or 
whether it gives off a characteristic odor. 

I. If the powder is entirely consumed by heat, the 
following stone constituents may be present : Uric acid, 
urates of sodium and ammonium, xanthine, proteine, and 
cystine. 

(1.) Proteine (fibrine) burns at a red heat with a 
brilliant yellow flame, and diffuses a strong odor of 
burning feathers or hair. 

(2.) Cystine burns with a weak bluish-white flame, 
and gives off a penetrating smell like burning fat and 
sulphur. The powder is dissolved in dilute ammonia, 
and shows under the microscope, upon evaporation of 
the same, beautiful hexagonal plates. 

(3.) Xanthine by the murexide test shows an orange- 
yellow color, and burns without a visible flame. 

(4.) Uric acid and sodium and ammonium urates 
burn without visible flame, and give with ammonia a 
beautiful red, and with KOH a beautiful violet mu- 
rexide. 

a. The urate of sodium is distinguished from the 
urate of ammonium, and from free uric acid, by the fact 
that on the foil upon which it has been heated there 
remains a light cloudiness. If a piece of red litmus 
paper is moistened with distilled water and laid upon 
this cloudy spot, a similar blue spot appears on the 
paper. This is caused by the sodium carbonate (or 



THE UBWE. 195 

caustic soda) which has been formed by heating the 
urate of sodium. The urate of ammonium and the free 
uric acid do not give this test. 

b. The urate of ammonium is distinguished from the 
free uric acid by the so-called cold ammonia test. This 
is accomplished as follows : Take a small test-glass, and 
to # l-O2 gramme of the powder to be tested add a few 
drops of a concentrated solution of KOH. This glass is 
then covered by a watch-glass which has on the convex 
surface a small piece of wet red litmus paper ; if after 
a few minutes the paper becomes blue, ammonia is pres- 
ent. 

c. Free uric acid gives naturally a negative result 
with the litmus test. 

II. If the powder is partially consumed, or is un- 
altered by heat, the stone consists essentially of calcium 
and magnesium salts. Then the following constituents 
may be present: Calcium oxalate, calcium carbonate, 
calcium phosphate, and ammonio-magnesium phosphate. 

(1.) Calcium oxalate does not effervesce upon the 
addition of a drop of HOI. By intense heat this 
powder shows a peculiar glow and decrepitates slightly. 
The oxalate of calcium is by this means transformed 
into the carbonate of calcium; and if now a drop of 
HC1 is added there ensues a brisk effervescence. 

(2.) Calcium carbonate effervesces upon addition of 
HC1 without first heating. (By this it is distinguished 
from the oxalate.) 

(3.) Calcium phosphates and the ammonio-magne- 
sium phosphate do not effervesce upon the addition of 



196 ANALYSIS OF THE URINE. 

a drop of HC1, either before or after incineration. (By 
this they are distinguished from the carbonate and ox- 
alate.) The incinerated powder is readily soluble in 
HC1. If we add to this solution ammonium hydrate 
[(NH 4 )OH] drop by drop until the solution has be- 
come alkaline, there appears a white flocculent precipi- 
tate, which consists of the amorphous basic calcium 
phosphate and the crystalline ammonio - magnesium 
phosphate. Under the microscope the triple phos- 
phate appears in stars or oblique crosses, while the 
calcium phosphate appears amorphous. Accordingly, 
from this precipitate we may conclude whether the 
calcium or the ammonio-magnesium phosphate is pre- 
dominant by the relative amounts of the amorphous 
and crystalline precipitates. 



CHAPTER IV. 

REAGENTS AND APPARATUS FOR THE APPROXIMATIVE 
DETERMINATION OF TEE CONSTITUENTS OF THE 
URINE. 

KEAGE1STS. 

Since the physician generally procures his reagents 
from the apothecary, for the sake of convenience we 
give the prescription formulae. For these reactions it is 
best to employ glass-stoppered bottles with wide necks, 
with a capacity of 250 c.c. 

A. Acids. 

1. Acid hydrochloric, concent., c. p., 200 grms. 

2. Acid sulphuric, concent., c. p., 200 grms. 

3. Acid nitric, concent., c. p., 200 grms. 

4. Acid acetic, concent., c. p., 200 grms. 

B. Bases and Salts. 

5. Potass, caust., alcohol dep., 100 grms. 
Aqua dest., 200 grms. 

6. Ammon., c. pur., liquid, 100 grms. 



> aa 30 grms. 



198 AXALFSIS OF TEE URINE. 

7. Barii chlorid. cryst., 30 grms. 
Aqua dest., 200 gmis. 
Acidi hydrochlor., 10 grms. 

8. Plumb, acet. cryst., 30 grms. 
Aqua dest., 200 grins. 

9. Cupri sulphat., 30 grms. 
Aqua dest, 200 grins. 

10. Magnes. sulphat., 
Sal ammoniac, depurat 
Aqua dest., 200 gnus. 
Amnion, c. pur., liquid, 50 grms. 

11. Argent, nitrat, 5 grms. 
Aqua dest., 40 grms. 

For the latter reagents a pipette is advantageous. 

12. Red and blue litmus paper in strips. 

Besides these necessary reagents, the following may- 
be employed for special cases : Distilled water, ferric 
chloride, basic acetate of lead, mercuric nitrate, basic 
nitrate of bismuth (magist. bismuthi), fuming nitric acid, 
potassium nitrite, starch, chloroform, ether, alcohol, 
iodine in iodide of potassium solution, acetic acid, so- 
dium chloride, and zinc chloride. 

APPARATUS. 

1. Six test-tubes, with rack. 

2. Ten wine-glasses or small test-glasses. 

3. Cylinder glasses of 100, 200, and 300 c.c. ca- 
pacity. 



REAGENTS AND APPARATUS. 199 

4. A graduated glass. 

5. A 100 c.c. flask, with a glass tube through the 
cork. 

6. A wash-bottle for distilled water. 

7. A urinometer. 

8. A spirit lamp. 

9. Two small porcelain evaporating dishes. 

10. A ring stand with two rings. 

11. Filter paper. 

12. Four glass funnels for filtering. 

13. Glass rods. 

14. A microscope with appurtenances. 

15. A large beaker of 3,000 to 4,000 c.c. capacity. 

For special cases we must have watch-glasses, beaker- 
glasses, and pipettes ; and for quantitative examination, 
a delicate pair of scales. 



CHAPTER V. 

QUANTITATIVE DETERMINATION OF A FEW OF THE 
CONSTITUENTS OF THE URINE. 

As a first step toward the quantitative investigation, 
the entire mass of the excreted urine must be collected 
for a given time. Usually the amount for twenty-four 
hours is collected, but it must be observed that before a 
stool one should urinate, that none be lost by being 
mixed with the faeces. It is inadmissible to attempt to 
determine the amount for twenty-four hours from the 
quantity collected in one hour (p. 36). 

The urine should be collected in graduated cylinders. 
For large amounts one may graduate a vessel himself. 
Take a flask containing 1 litre of water at 15° C, 
and pour into the cylinder to be graduated, making a 
mark on the glass at the surface of the fluid, repeating 
this as often as necessary. 

If one desires to ascertain the mean amount of the 
urine excreted by an individual, the total amount should 
be collected for several days, and the quantity be di- 
vided by the number of days. 



QUANTITATIVE DETERMINATION. 201 

L ESTIMATION OF THE DEGBEE OF ACIDITY. 

In order to ascertain the degree of acidity of the 
urine, we add Na OH to the same until it reaches the 
point of neutralization, and then compute how much 
acid (we usually employ oxalic) is required to neutral- 
ize the quantity of sodium hydrate used. 

a. Volumetric Solution, 

We employ a one-tenth Na OH solution, which in 
1 c.c. contains 0*0031 grm. NajO, which is sufficient to 
neutralize 0*0063 grm. of crystallized oxalic acid. If 
we employ normal sodium hydrate, we add 10 times its 
volume of distilled water. (Description of normal 
sodium hydrate, Mohr, " Titrirmethode," 4th edition, 
p. 83.) 

b. Example. 

We pour exactly 100 c.c. of urine into a beaker-glass, 
and add while stirring the sodium-hydrate solution drop 
by drop from a burette, until a drop of the urine on red 
litmus paper shows no blue and on blue litmus paper no 
red spot. The number of c.c. of NaOH solution added 
(say 14) we multiply by 0*0063, and the product 
(0*0882 grm.) shows the acidity of 100 c.c. of urine 
expressed in crystallized oxalic acid. 

H. ESTIMATION OF THE SOLID MATTERS. 

In order to estimate the solid matters, we take 10 
c.c. of urine in a weighed porcelain dish, and evaporate 



202 ANALYSIS OF THE URINE. 

on a water-batli to dryness. It should then be kept for 
an hour in a drying chamber at 100°, and then allowed 
to cool in a desiccator. We now weigh and replace 
the dish in the drying chamber, weighing again at the 
expiration of an hour after cooling as before, repeating 
this until there is no variation in weight. The differ- 
ence of weight between the empty dish and that con- 
taining the solids is the weight of the solid matters in 
10 c.c. of the urine. Unfortunately the result is always 
too small, for the action of the acid sodium phosphate 
on the urea at this temperature decomposes the latter, 
and ammonia and carbonic acid are driven off at the 
same time with the water. 

It is seldom that the physician employs this means 
for the investigation of the amount of solids, for by 
using Haser's or Trapp's coefficients as satisfactory re- 
sults are obtained, at least for him. (See p. 39.) 



m. ESTIMATION OF UREA. 

Liebig^s Method, 
a. Reagents. 

1. Baryta solution. — One volume of a cold saturated 
solution of barium nitrate is mixed with two volumes 
of a cold saturated barium hydrate solution. 

2. Volumetric mercuric reagent. — This is a solution 
of mercuric nitrate (in which there must be no basic 
-alt or mercurous compound), of such concentration that 
in 1,000 c.c. of the solution 71*48 grms. of pure mercury 



QUANTITATIVE DETERMINATION. 203 

or 77*2 grms. of pure mercuric oxide (dried at 100°) 
are contained. See Neubauer and Vogel, 1. a, 183 ; 
Mohr, 1. a, 48, 1.) 

3. Sodium carbonate solution. — For Kaudenberg's 
modification we employ sodium-hydrogen carbonate. 

b. Method of Procedure. 

We take up 40 c.c. of urine in a pipette, and add 20 
c.c. of the baryta solution. Here, as in all other cases 
of quantitative work, the greatest care must be exer- 
cised. In the pipette there should be no foam, and one 
should read the division mark on the pipette which corre- 
sponds to the lower edge of the meniscus. We must be 
especially careful that none of the fluid be lost. If we 
have treated the urine with the baryta solution, the pre- 
cipitate of phosphates and sulphates which has sepa- 
rated should after some time be filtered off, using a dry 
filter-paper and allowing the fluid to run through into 
a dry beaker. The filtrate is therefore one third baryta 
solution and two thirds urine from which the sulphates 
and phosphates have been removed. We now take 
15 c.c. of this clear fluid by using a pipette, and allow 
it to flow into a dry glass vessel. This contains 10 c.c. 
of urine. Now, from a burette filled precisely to the 
zero point with the mercuric nitrate mixture, we add 
about as many cubic centimetres of the mixture as are 
denoted by the last two figures of the specific gravity of 
the urine (i. e., 15 c.c. if the specific gravity is 1*015), 
and try whether the limit has been reached. For this 



204 ANALYSES OF THE URIBR 

purpose we place a drop of the well-stirred mixture by 

means of a clean glass rod on a glazed white porcelain 
plate, and in the centre of this drop add a small drop of 
a concentrated solution of sodium carbonate. If there 
occurs at the rim of contact of the fluids no rusty brown 
zone, we proceed to add more of the mercuric nitrate 
solution. If, however, even a faint rusty brown ring 
occurs, we know that the limit has been reached. 

The first effect of the addition of the mercuric 
nitrate is an exchange of bases with the alkaline 
chlorides present, forming Hg CL (corrosive sublimate) 
and an alkaline nitrate. The chlorides having been 
thus disposed of. the excess of mercuric nitrate com- 
bines with the urea, forming 2 CO H. X ; . X- G=. 4HgO. 
which is a white precipitate. This precipitate dissolves 
I aome cxtt-nt in a slight excess of acid, from which it 
may be brought down white by rendering the solution 
neutral, on adding sodic carbonate. As soon, however, 
as the urea is all satisfied, a further addition of the mer- 
curic compound remains in the solution, and then gives 
a yellowish or brownish precipitate of basic mercury 
salt on neutralizing with the sodic carbonate, and the 
<>f the reaction is indicated. Since the presence of 
chloride- deprives the mercuric nitrate of its power to 
precipitate the urea, the determination is inaccurate in 
bo far as chlorides are present For that reason the 
mercury solution is made a little stronger than the 
theory I a. If the mi tarns 1 to 1-J per cent 

of sodium chlorid* ■_ . of the mercury solution must 
be Bubtracted frorn the amount _ ve approxi- 



QUANTITATIVE DETERMINATION. 205 

mately accurate results, assuming that 15 c.c. of the 
urine is used.* The property which the chlorides pos- 
sess of destroying the precipitating power of mercuric 
nitrate upon the urea may be used to determine the 
amount of chlorides present, f 

When the mercuric-nitrate solution has been added 
in sufficient quantity, we allow the burette to stand for 
several minutes, and then read off how many cubic cen- 
timetres had been used. 

The reagent is so compounded that 1 c.c. of the solu- 
tion satisfies 10 milligrammes of urea. If we have em- 
ployed 20 c.c. of the reagent, then is 1 c.c. : 10 mil- 
ligr. : : 20 c.c. : x (= 200 milligr.). Consequently, if 
we have used 20 c.c. of the mercuric reagent, then must 
200 milligr. of urea have been present, which has en- 
tered into combination with the mercury. This was 
contained in the 15 c.c. of the urine and baryta mixture 
(which contained 10 c.c. of urine). We have therefore 
as a consequence : 

In 10 c.c. of urine are 200 milligr. of urea ; so in 
1,250 c.c. (the amount for twenty-four hours) we have 
10 : 200 : : 1250 : x ( = 25,000 milligr. = 25 grms.). 

1. Since the mercuric reagent is intended for a 2 per 
cent, urea solution, we only obtain exact results when 
to 15 c.c. of a 2 per cent, urea solution we add exactly 
30 c.c. of the reagent ; for 1 c.c. satisfies exactly 10 mil- 
ligr. of urea. 

Each c.c. of the reagent requires 72 milligr. of HgO, 

* Neubauer and Vogel, second edition, 1856, p. 106. 
t Neubauer and Vogel, p. 94. 



206 ANALYSIS OF THE URINE. 

according to the computation, in order to combine with 
10 milligr. of urea. In addition, however, a certain 
excess of HgO is necessary for the final reaction. Ac- 
cording to Liebig's calculations, this amounts per c.c. 
to 5*2 milligr.; hence in 30 c.c. we have 30 X 5*2 = 
156 milligr. (excess of HgO). If we have added to 
15 c.c. of the 2 per cent, urea solution 30 c.c. of the 
volumetric reagent, then the mass of the mixture con- 
sists of 45 c.c, which contains 156 milligr. of excess of 
HgO ; that is to say, each c.c. contains 156 -j- 45 = 3*46 
milligr. Therefore for a distinct final reaction every c.c. 
of the mixture must contain 3*46 milligr. of HgO. 

If 15 c.c. of the urea solution contains 3*5 per cent. 
of urea, this would require 52*5 c.c. of the volumetric 
mercuric reagent. The mixture consists of 15 -\- 52*5 = 
67*5 c.c. In the 52*5 c.c. of the volumetric reagent are 
52*5 X 5*2 = 273 milligr. of excess of HgO; hence in 
every c.c. there are 4*04 milligr. The final reaction 
occurs, however, with 3*46 milligr. In this case we have 
consequently 0*58 milligr. per c.c. too much free HgO. 
Therefore the final reaction would occur sooner. 

If, on the contrary, the solution contained but 1 per 
cent, of urea, we would have an error in the opposite 
direction. 

In order to eliminate both errors we proceed as fol- 
lows : 

(//.) If more than 30 c.c. of the volumetric reagent 
have been employed, before the sodium carbonate test 
we must add one half as many c.c. of water, as the ex- 
cess in c.c. of the volumetric mercuric reagent we have 



QUANTITATIVE DETERMINATION. 207 

employed ; i.e., having used 52*5 c.c. of the reagent, we 
add 52 ' 5 ~ 30 = 11 c.c. of water to the mixture before the 
soda test. 

(h.) If less than 30 c.c. of the fluid have been em- 
ployed, for every 5 c.c. less than 30 we must deduct 0*1 
c.c. from the amount used. For example, we have used 
20 c.c. (10 c.c. less) ; consequently, we employ 20 — 0*2 
= 19*8 c.c. in the computation. 

2. If the urine contains from 1 to 1*5 per cent. Na CI, 
a greater quantity of the volumetric mercuric reagent 
is required. If without correction we estimate the 
urea, we find the quantity (15 to 25 milligr.) too great. 
In order to correct this error, we subtract 2 c.c. from 
the amount of the volumetric mercuric reagent used. 
For example, if we have employed 30 c.c. of the reagent, 
30 — 2 = 28 c.c. must be used in the computation of 
urea. 

If the absolute amount of urea alone concerns us, 
without considering it relatively, we must either preci- 
pitate the Na CI by means of a nitrate of silver solution 
or by Eautenberg's method. For this we take two 
samples of urine 15 c.c. each, and render one weakly 
acid with HISr0 3 . We then drop in the volumetric mer- 
curic reagent until a permanent turbidity ensues. Then 
we note the number of c.c. we have employed, and then 
with the other sample make a determination of the 
amount of urea after Liebig's method. The mixture, 
however, must be made neutral by addition of freshly 
precipitated calcium carbonate. For the final reaction 
we employ, instead of the soda solution, sodium-hydro- 



208 AXALYSIS OF THE URINE. 

gen carbonate in water (see p. 203). From the number 
of c.c. we have employed in the last test we subtract the 
number used in first sample, and from their difference 
we estimate the urea. If in the first sample we used 1*5 
c.c. and in the second 31 c.c, we then employ in the de- 
termination 31 — T5 = 29*5 c.c. 

3. If albumen is present in the mine, a stoppered 
flask of 200 c.c. capacity should be employed, and the 
urine after the addition of a few drops of acetic acid 
should be heated until the albumen has separated in 
flakes from the clear urine. After closing the flask and 
allowing it to cool, the filtrate should be used in the 
usual manner. 

2. Bun-sen's Method (Bunge). 

This is only applicable to urines free from albumen 
and sugar. By it 50 c.c. of urine are treated with 25 
c.c. of a saturated ammoniacal barium-chloride solution, 
and filtered through a thick filter-paper ; then 15 c.c. of 
the mixture (containing 10 c.c. of urine) are poured into 
a thick-walled tube so that the sides are not sprinkled 
by the mixture. At the bottom of the closed tube have 
been placed about 3 grms. of crystallized chloride of 
barium. After the urine has been added, the tube 
should be sealed about three fingers above the fluid. 
The tube is now placed in an oil-bath and heated for six 
hours at a temperature of 220° to 240°. After cooling, 
the point of the tube is broken off, and the resulting 
barium carbonate is placed upon a filter and carefully 
washed, then dissolved in a proper amount of HC1. 



QUANTITATIVE DETERMINATION. 209 

Should some of the barium carbonate, after the washing 
of the tube with water, still adhere to the sides, it should 
be dissolved by a drop or two of HC1. The united solu- 
tions are then filtered, and the nitrate is precipitated 
with H 2 S0 4 . After some time the precipitated barium 
sulphate is collected on a filter, washed, heated to red- 
ness, and weighed. 

Since 233 grms. of barium sulphate correspond to 60 
grms. of urea, the weight of the urea may be estimated 
by a simple calculation. 

3. Knop-Huf Tier's Method, 
a. Reagents. 

1. Knop's fluid (hypobromite of sodium). In 250 
c.c. of water 100 grms. of caustic soda are dissolved, and 
after cooling 25 c.c. of bromine are added. This should 
be freshly prepared. 

2. Cold saturated chloride of sodium solution. 

b. Mode of Procedure. 

The lower bulb and stopcock of Hufner's apparatus 
(the capacity having been accurately determined) are 
filled with a mixture of 10 c.c. of urine diluted with 
40 c.c. of water. The cock is then closed, no bubbles 
being allowed to remain. The second and larger bulb, 
connected by means of the stopcock with the lower 
bulb and opening above into the basin, is now washed 
with water and filled with Knop's fluid, diluted with an 



210 ANALYSIS OF THE URINE. 

equal volume of water. The basiu is then sufficiently 
filled with the sodium-chloride solution, and the eudi- 
ometer filled with water is inverted, the mouth below 
the surface of the sodium chloride solution in the basin, 
and placed over the narrowed neck of the second bulb, 
being retained in this position by the clamp above. 
The stopcock is then turned, and for a few minutes a 
violent evolution of gas is observed. After an hour the 
eudiometer may be withdrawn and the amount of the 
contained nitrogen estimated by Dumas's method. One 
gramme of urea furnishes 370 c.c. of nitrogen, at 0° C. 
and under 760 mm. pressure. 

[A description of a ureometer devised for the rapid 
estimation of urea, by Prof. Charles Doremus, which is 
the simplest and most reliable method for approxima- 
tive tests, is given in the "Journal of the American 
Chemical Society," Vol. VII., No. 3, 1885, and also in 
the " New York Medical Kecord," Vol. XXVII., No. 
11, p. 307.] 

IV. DETERMINATION OF UEIC ACID. 

To 300 c.c. of urine are added 10 c.c. of HC1 ; the 
mixture is stirred briskly with a glass rod and allowed 
to stand forty-eight hours in a cool place. If the urine 
contains albumen, it should be removed by the method 
given on p. 208. If it contains sugar, 500 c.c. should be 
treated with mercuric acetate, and the precipitate washed 
upon the filter, then suspended in a little water and 
treated with hydrogen sulphide. The mercuric sul- 



QUANTITATIVE DETERMINATION. 211 

phide is then washed with warm water, and the united 
wash-waters and nitrate treated with HC1. 

The separated uric-acid crystals should be collected 
on a weighed filter-paper which has been washed with 
HC1 and water and dried between two watch-glasses at 
a temperature of 100° C. 

By collecting the uric acid the work is essentially 
lightened. The crystals lie mostly on the bottom of the 
glass ; a part, however, adhere to the walls, and a few of 
the smallest float on the surface. Since the uric-acid 
crystals have a high specific gravity, they precipitate 
very quickly (after one to two minutes). Those cling- 
ing on the side walls may be disturbed by means of 
a goose-feather clipped except at the end. The dis- 
engaged crystals settle very quickly, so that one may 
easily decant the clear fluid above into another cylinder, 
and bring the remaining fluid and the precipitate upon 
a small filter. Should any of the crystals go over with 
the decanted fluid, they quickly settle, and may be saved 
and brought upon the filter by decanting again. We 
decant in this way until no more crystals remain in the 
urine. If the crystals are very small, recourse must be 
had to filtration. 

The crystals are then washed with water until 
Ag N0 3 no longer renders the filtrate cloudy. It is a 
good precaution not to employ more than 30 c.c. of 
water; otherwise some of the uric acid will be dis- 
solved. If more than 30 c.c. is used, for each c.c. one 
must add 0*045 milligr. to the amount of uric acid deter- 
mined. 



212 ANALYSIS OF THE UEIXE. 

When the uric acid lias been washed, it should be 
dried for several hours between watch-glasses at 100° 
C, then cooled in a desiccator and weighed. 

The difference between tbe weight of the watch- 
glasses when empty and when containing the uric acid 
gives the weight of the uric acid contained in 300 c.c. 
of urine. 

Schwanert recommends as a correction, for every 
100 c.c. of urine, 0*0048 grm. to be added. 

V. DETEE MENTATION OF CEEATENTKE. 

a. Reagents. 

1. Chloride of zinc solution. Pure zinc oxide is dis- 
solved in pure HC1, and the solution evaporated on a 
water-bath (until no free HC1 is present) to a thick 
sirup. This is dissolved in strong alcohol, and the 
solution diluted until it has a specific gravity = 1-200. 

2. Milk of lime, which is stirred up before using. 

3. Diluted chloride of calcium solution. 

b. Mode of Procedure. 

We render 200 c.c. of urine alkaline with milk of 
lime, and add diluted chloride of calcium solution as 
long as a precipitate forms. After two hours we filter 
and wash the residue, then quickly evaporate the wash- 
water and filtrate on a water-bath to a thick sirup. 
While it is yet warm, 50 c.c. of 95 per cent, alcohol are 
added to the mixture, and the same is transferred to a 
hoaker-glass — washing the dish with a little alcohol — 



QUANTITATIVE DETERMINATION-. 213 

and allowed to stand for eisrht hours. Then the mix- 
ture is filtered through a small filter and the residue 
washed with more alcohol. The united filtrates are 
then evaporated down to 60 c.c. After cooling, \ c.c. 
of the above-mentioned chloride of zinc solution is 
added, and the mixture stirred briskly with a glass rod 
until turbidity occurs. It is then allowed to stand 
forty-eight hours in a cool place. We now collect the 
separated creatinine chloride of zinc on a small filter, 
and weigh after washing (as by the described method 
for uric acid). In 100 parts of creatinine chloride of 
zinc are 62*44 parts of creatinine. 

VI. DETEEMINATION OF THE TOTAL AMOUNT OE NITEO- 

GEN. 

The chief amount of nitrogen in the urine is con- 
tained in the urea, and since, in Liebig's method for the 
separation of the same, other bodies containing nitrogen 
fall in connection with the urea, so in the greater num- 
ber of observations the amount of nitrogen present may 
be calculated approximatively from Liebig's determina- 
tion of urea. 

a. Reagents. 

1. Freshly calcined soda-lime. 

2. Normal sulphuric acid, which contains 40 grms. 
of anhydrous acid in every litre. Each c.c. corresponds 
to 0*014 grm. of nitrogen. (" Darstellung," Neubauer 
and Vogel, 1. c, p. 246 ; Mohr, 1. c, p. 74.) 

3. Sodium hydrate, which is an equivalent of the 



•214 AWALYWB OF TEE UBINK 

II.SO.: L e., 10 c.c of the one must exactly neatm 
e. of the other. 
4. Tincture of lit urns. 

b. Mode of Procedure. 

Pour 20 c.c. of normal ILS0 4 carefully into a Var- 
rentrapp and Wills* nitrogen bulb apparatus. In a 
strong flask of 100 c.c. capacity, containing a layer of 
soda-lime 2 c.c. thick, is poured 5 c.c. of urine, and the 
flask quickly closed with a double-perforated stopper 
and buried to the neck in a sand-bath. Through one of 
the perforations a tube leads to the nitrogen apparatus, 
and the other is supplied with a finely drawn-out sealed 
glass tube. The sand-bath is heated as long as bubbles 
pass through the nitrogen apparatus. TThen these cease 
the end of the glass tube is broken off, and all the am- 
monia is drawn from the flask by careful asjDiration. 
Xow pour the contents of the nitrogen apparatus into a 
beaker-glass, wash well with water, add a few drops of 
litmus tincture, and then add the sodium-hydrate solu- 
tion from a burette until the red color changes to 
blue. 

If no ammonia had been generated by the distillation 
of the urine, 20 c.c. of the sodium hydrate would have 
to be added to neutralize the 20 c.c. of H 2 S0 4 . If 14 
cc. i- however found to be sufficient, we know that 6 
c.c. of H 2 S0 4 have been satisfied by the ammonia formed. 
Since 1 c.c. of the acid corresponds to 0*014 grni. of 
nitrogen, then the total amount of nitrogen which has 



QUANTITATIVE DETERMINATION. 215 

gone to form ammonia would be 6 X 0*014 == 0'084 grm. 
This would be given off by 5 c.c. of urine. Hence, if 
we had employed the whole amount of urine excreted 
in twenty-four hours (say 1,500 c.c), we would have the 
amount indicated in the proportion 5 : 0'084 : : 1,500 : %, 
= 25*2 grms., which is the total amount of nitrogen ex- 
creted in twenty-four hours. 



VII. DETEEME^ATIOX OF ALBUMEN. 

Pour into a beaker-glass 100 c.c. of filtered urine if a 
slight amount of albumen is present, or 50 c.c. if a mod- 
erate amount is present, or 20 c.c. if rich in albumen. 
In the second case add 50 c.c, and in the last 80 c.c of 
water, and heat for half an hour on a water-bath. 
Should the albumen not have separated in large flakes, 
then one or two drops of acetic acid should be added 
and the heat again applied. As soon as the fluid has 
become clear it should be filtered through a small plaited 
filter-paper which has been previously weighed (see uric 
acid determination, page 210), taking care that all the 
coagula should be brought upon the filter, if necessary 
by the aid of a feather, and the beaker washed with hot 
water. Then the coagulated albumen should be washed 
into the point of the filter, and further washed with hot 
water until chlorides can no longer be detected in the 
filtrate by the AgN0 3 test. Then dry between watch- 
glasses at 100° until no loss of weight is observed. The 
determination of the total amount excreted in twenty- 
four hours is easily calculated from this. 



216 I RSKB : THE UETXE. 

If has a good polariz ig :us. the amount 

of albumen may be easily determined, pi I no 

sugar if :. 

vecl i -it:-:: . , ::^at:o>" of srGAR. 
L Fehl '• MeOi 

a. Yd-'j-m-trk- Solution. 

Fehling'fi solution. In 1. ,:. there are 34*639 

grins, of eupric sulphate, 173 grmsi of pure crystalline 
tartrate of sodium and potassium, and . grma of 
caustic soda solut: i ::' specific gravity 1"12. ("Dar- 
Btennng, 71 NTeubauer and Vogel, 1. e.. 206.) Of this so- 

totion 10 :.<:. are reduced by 0-05 gnn, of sugar.* 

: Mode of P v. 

The lepends upon the property that 

grape sugar possesses ::' reducing the eupric sulphate in 
the presence of an alkali. For this in :ion a small 

amount of filtered urine is taken which has been largely 
diluted with water, unless it has previously been ascer- 
tained that only traces of sugar are present. Usually 
f urine and 1 : water are employe'!. A 

bur :th this mixture exactly to the zero 

mark. Then 1 >f Fehling's solution are poured 

[* This fluid is best preserved by beins put into small vials i'20— 30 c.c. 
capacity) and kept in the dark. Before using as a quantitative test a 
portion should be boiled, and if a precipitate occur the liquid should be 
freshly prepared. The liquid test is preferable to the pellets now on the 
market.] 



QUANTITATIVE DETERMINATION. 217 

into a flask or porcelain dish and diluted with 40 c.c. 
of water, then heated over a flame, having previously 
protected the flask with a piece of wire gauze. As 
soon as the copper solution begins to boil, the urine is 
added drop by drop from the burette. Soon the fluid 
becomes yellow, then red, and finally the last trace 
of the blue color disappears, and the red suboxide of 
copper rapidly subsides when the source of heat is re- 
moved. If allowed to stand for some time, the origi- 
nally blue solution is seen to be colorless, or slightly 
yellow if more urine has been added than was neces- 
sary for the reduction of the copper. The entire loss 
of color of the fluid is consequently the limiting point 
of the reaction. 

Since with the unaided eye it is not easy to deter- 
mine when the fluid is colorless* and inclined not to 
any tint whatsoever, it is advantageous to pass a few 
drops of the fluid through a small filter and divide 
the filtrate into two parts, one of which after acidify- 
ing with acetic acid is tested for copper with ferrocy- ■ 
anide of potassium, and the other with Fehling's solu- 
tion for sugar. If by this method we obtain no re- 
action for either copper or sugar, neither is present in 
excess, and consequently the limiting point of the re- 
action has been reached. 

In the determination of the amount of sugar, the 
quantity of urine employed must be known. If 25 c.c. 

[* Pavy has modified this test by the addition of ammonia to prevent 
the precipitation of the red oxide, which renders it difficult to distinguish 
the point of final reaction. For an account of his method, also called the 
" ammonio-cupric," see " London Lancet," March 1, 1884, p. 376.] 



218 ANALYSIS OF THE URINE. 

of the urine mixture were necessary to reduce 10 c.c. 
of Fehling's solution, the urine mixture being so made 
up that in 200 c.c. of it there were contained 10 c.c. 
of urine (the remainder water), then if x = amount 
of urine in 25 c.c. of the urine mixture (the amount 
employed), we would have 200 : 10 : : 25 : x = 1*25 c.c. 
of urine. 

In this case 1*25 c.c. of the urine was necessary to 
reduce 10 c.c. of Fehling's solution. Now this solution 
is so constituted that for the complete reduction of 
10 c.c. of the same it is necessary to have 50 milligr. 
of sugar. Since, however, 1*25 c.c. of the urine has 
effected this reduction, it is certain that this quantity 
must have contained 50 milligr. of grape sugar. Hence 
it is easy to calculate the sugar in the entire amount 
for the twenty-four hours. 

If, for example, a diabetic patient had excreted 
5,000 c.c. of urine, we would have 1*25 c.c. : 50 milligr. 
: : 5,000 c.c. : x = 200,000 milligr., or 200 grins, of sugar. 

If albumen is present, it must be separated before- 
hand in the usual manner. 

2. Knapp's Method. 

a. Volumefric Solution. 

Ten grms. of pure dried mercuric cyanide are dis- 
solved in some water ; 100 c.c. of sodium hydrate (spe- 
cific gravity T145) are added, and the whole diluted to 
1,000 c.c; 40 c.c. of this solution are reduced by 100 
milligr. of sugar. 



QUANTITATIVE DETERMINATION. 219 

b. Mode of Procedure. 

Forty c.c. of the volumetric solution are heated in a 
beaker-glass, and urine added as in Fehling's method 
until the originally turbid mixture becomes clear and 
yellowish. From time to time a drop of this is thrown 
on a filter paper and touched with a rod dipped in am- 
monium sulphide. As soon as the spot no longer shows 
a brown edge, the reaction is complete. The method 
does not give quite as accurate results as Fehling's. 

The fermentation method is more complicated and 
unreliable than Fehling's. Very exact results are ob- 
tained by Soleil-Ventzke's saccharimeter or Wild's po- 
laristrobometer.* 

IX. DETERMINATION OF CHLORINE. 

1 Mohr's Method, 
a. Reagents. 

1. Cold saturated solution of neutral chromate of 
potassium. . 

2. Volumetric nitrate of silver solution, which con- 
tains in the litre 29*075 grms. of nitrate of silver (18*469 
grms. Ag), so that 1 c.c. of the same corresponds to 10 
milligr. of sodium chloride (= 6*065 milligr. chlorine). 
(Neubauer and Vogel, 1. c, 194.) 

3. Calcium carbonate, freshly prepared. 

b. Mode of Procedure. 

Ten c.c. of urine are poured into a platinum crucible, 
and 2 grms. of potassium nitrate free from chlorine are 

* See description of Ultzmann's saccharimeter, p. 301. 



220 ANALYSIS OF THE URINE. 

added, and the fluid evaporated on a water-bath to dry- 
ness. Heat the residue first gently, then intensely, over 
a Bunsen's burner, until the fused mass contains no car- 
bon (is white). The slag is dissolved in water and the 
dish carefully washed. Solution and wash-water are 
put in a beaker and treated carefully with a much 
diluted nitric acid, free from chlorine, until the fluid 
possesses a weakly acid reaction, which is again neutral- 
ized by freshly precipitated calcium carbonate. With- 
out regard to the sediment, three drops of the potassium- 
chromate solution are added, and the volumetric fluid 
then allowed to run in from a burette. As soon as the 
yellowish solution becomes reddish, it is a sign that 
all the chloride of sodium has been changed to silver 
chloride, and the formation of the red silver chromate 
begins. At this point the reaction is complete. 

If to 10 c.c. of urine employed 9*6 c.c. of the volu- 
metric solution has been added, since 1 c.c. of the same 
corresponds to 10 milligr. of Na CI, 9*6 c.c. shows 96 
milligr. of chloride of sodium. 

If in 10 c.c. of urine 96 milligr. of Na CI are con- 
tained, then in the twenty-four hours' amount, i. e., 
1,400 c.c, we would have 10 : 96 :: 1,400 : x = 13*44 
grms., of Na CI in the amount for twenty-four hours. 

Should the patient have taken an iodine or bromine 
preparation previous to the investigation, this will 
quickly pass into the urine. In order to correct the 
disturbance from this cause, the solution of the slag is 
acidified with HN0 8 , and a few drops of a solution of 
potassium nitrite are added in order to make certain the 



QUANTITATIVE DETERMINATION. 221 

separation of the iodine. It is then shaken up with 
carbon disnlphide until this no longer takes up iodine 
(or bromine) ; the solution is then neutralized with 
sodium carbonate, evaporated, and treated as above. 
(Salkowski.) 

Falck's method is founded upon the precipitability 
of sulpho-cyanates, and the property of deprivation 
of color which AgNo 3 has over the red ferric sulpho- 
cyanate. 

X. DETEEMrNATION OF PHOSPHOEIC ACID. 

a. Reagents. 

1. Sodium-acetate solution : 100 grms. of acetate of 
sodium are dissolved in 900 c.c. of water, and to that 
solution 100 c.c. of acetic acid are added. 

2. Uranium nitrate solution, 1,000 c.c. of which 
must contain 20*3 grms. of pure uranic oxide: 1 c.c. 
corresponds to 5 milligr. of phosphoric acid. (Neu- 
bauer and Vogel, 1. c, 199.) 

3. Ferrocyanide of potassium solution. 

b. Mode of Procedure, 

Fifty c.c. of the urine to be investigated are poured 
into a beaker-glass and 5 c.c. of the sodium-acetate solu- 
tion are added. This mixture is then warmed on a 
water-bath. When the urine is warm, the uranium 
solution is added drop by drop as long as a precipitate 
is observed. If this can not be recognized with cer- 
tainty, the mixture must be stirred up, a drop brought 
upon a porcelain plate, and a drop of a very dilute solu= 



222 ANALYSIS OF THE URINE. 

tion of potassium ferrocyanide added. If a brownish- 
red color appears at the line of contact, the addition of 
the uranium solution must be discontinued, and the dish 
placed again on the water-bath until the mixture sim- 
mers. Then we try again whether the limit of the 
reaction has been reached ; usually this is not the case, 
so the uranium solution is dropped in until the end of 
the reaction is reached. The limit of the reaction occurs 
when all the phosphoric acid has been precipitated by 
the uranium solution. After this condition is reached, 
the next drop of the uranium solution, finding no phos- 
phoric acid, forms a brown precipitate with the ferro- 
cyanide of potassium. 

If we have used 13 c.c. of the uranium solution, 
then, since 1 c.c. of this satisfies 5 milligr. of phosphoric 
acid, we have the proportion, 1:5 : : 13 : x — 65 milligr. 
The 65 milligr. are contained in 50 c.c. of urine; hence 
for the entire phosphoric acid in the twenty-four hours' 
amount we have the proportion, 50 : 65 : : 1,300 : x = 
1,690 milligr., or 1.69 grm. phosphoric acid. 

If we wish to determine the phosphoric acid in com- 
bination with the earths, 200 c.c. of urine are precipitated 
with ammonia and collected after twelve hours on a 
filter, and washed with ammonia water (1 part ammonia 
and 3 parts water). The filter is then broken at the 
point, and the precipitate washed down with a stream 
of water from a wash-bottle into a beaker-glass, and dis- 
solved while warm with as little as possible of acetic 
acid. Add 5 c.c. of sodium-acetate solution, diluted to 
50 c.c, and proceed as above. 



QUANTITATIVE DETERMINATION. 223 

Of course the difference between the total amount 
of phosphoric acid and the amount in combination with 
the alkaline earths will be the quantity combined with 
the alkalies (K.JSTa and NH 4 ). 



XI. DETERMINATION OF SULPHURIC ACID. 

One hundred c.c. of urine are heated with chloride 
of barium solution after acidification with HC1, and the 
precipitate of barium sulphate is brought upon a small 
filter-paper, the weight of whose ash is known, and 
washed until the filtrate gives no baryta reaction. Then 
the filter-paper and precipitate are incinerated in a plati- 
num crucible, moistened with a few drops of sulphuric 
acid, and again heated to redness. After cooling under 
a desiccator the mass is weighed. If the weight of the 
crucible and the ash of the filter is subtracted from the 
total weight, we have the weight of the barium sul- 
phate, from which the weight of the H 2 S0 4 may be 
easily calculated, since in 100 weighed parts of barium 
sulphate are contained 34° 3 3 parts of sulphuric acid 
(S0 8 ). 

The amount of sulphuric acid may be determined 
volumetrically, although this method is attended with 
much complication and is seldom employed. 

For the seldom used quantitative determination of 
the alkalies and alkali-earths, of indican, ammonia, biliary 
acids, and iodine, the works of Neubauer and Vogel, 
Hoppe-Seyler, etc., may be consulted. 



CHAPTER VI 

KEY TO THE APPROXIMATIVE ANALYSIS OE WROTE. 

After the urine has been allowed to stand some 
hours, its physical characteristics should first be observed. 

1. The twenty-four hours' amount. 

2. Color and transparency. 

3. Odor. 

•4. Reaction upon litmus. 

5. Specific gravity. 

6. Quantity of the sediment. 

If a sediment has formed, the urine must be poured 
off and made use of for the several chemical tests. If 
the urine is quite cloudy, it should be filtered ; should 
it not then be quite clear, it may be advantageous to 
warm it slightly to render it so. The sediment is set 
aside for analysis. 

CHEMICAL INVESTIGATION. 

j 1 Nitric j Vcid. 

Take al »< »ut 1 5 e.c. < 1 clear urine in a wine-glass, and 
pour down the aide <>f the glass a sab-layer of pnre 
nitric acid ( HNO t ). We find by this — 



KEY TO APPROXIMATIVE ANALYSIS. 225 

1. Albumen (p. 91) ; 

2. Urates (p. 60) ; 

3. Biliary coloring matters (p. 131) ; 

4. Indican (p. 66). 

If the urine contains much iodine, the zone between 
the fluids is colored a brilliant yellow-brown. The 
odor of iodine is perceived distinctly (p. 145). 

If but small amounts of these matters are present, 
they appear only after a few minutes. It is well to set 
the glass aside, while proceeding with the following test. 

B. Heat Test. 

Fill a test-tube one third full of clear urine, and heat 
over a spirit lamp. If a turbidity arises, then it contains 
either albumen or the earthy jphosjphates, which are preci- 
pitated by heat. Add now one or two drops of acetic 
acid : the earthy phosphates will be dissolved, but the 
albumen remains. Add now potassium hydrate in vol- 
ume equal to one half that of the urine in the tube : the 
albumen will go into solution, and the earthy phosphates 
will precipitate in small flakes. Heat the mixture again : 
if it becomes brown, sugar is present. If it does not 
become brown by boiling, set the tube aside in order to 
allow the phosphates to settle, that their amount and 
color may be noted. 

The earthy phosphates of normal urine are white. 
If they appear colored, the urine may contain various 
coloring matters ; if blood-red or dichroic, blood-coloring 
matters are present. As a confirmation of this, albumen 

15 



226 ANALYSIS OF THE URINE. 

must be present, and the crystals of liEemine should be 
tested for in the sediment of the urine which forms 
naturally, micro-chemically, or from the albumen coagu- 
luni tinged by the coloring matters, by means of the 
same test (p. 128). Also under the microscope we 
almost always find blood-corpuscles in the urine sedi- 
ment. 

If the earthy phosphates appear rose-red, and there 
is no albumen present, plant-coloring matters are indi- 
cated (p. 127), especially after the internal use of 
rhubarb and senna. As a confirmatory test we add 
ammonia to the raw urine : a reddish color appears, 
which vanishes on addition of acid. 

If the earthy phosphates appear a dirty gray, usu- 
ally uroerytlir ine (p. 126), the coloring matter of febrile 
urine is present. To confirm this there must be pres- 
ent a rose-red sedimentum lateritium, or, upon addition 
of a few drops of acetate-of-lead solution, a reddish or 
flesh-colored precipitate should fall. 

If the earthy phosphates appear brown, usually the 
biliary coloring matters are present. If the biliary col- 
oring matters are not decomposed, a beautiful irides- 
cence may be obtained by Heller's test (p. 132). If no 
coloration occurs, and also no green color is obtained 
(Ultzmann's test), then decomposed biliary matters are 
present in the urine. By a relatively low specific 
gravity of the urine the HoS0 4 test is strengthened, 
and a mixture of the urine with potassium hydrate 
(KOH) appears more darkly colored. 



KEY TO APPROXIMATIVE ANALYSIS. 227 

C. Test for the Normal Coloring Matters of the Urine. 

1. Test with concentrated H 2 S0 4 (p. 67, Heller's 
urophgeine test). 

2. Test for indican with concentrated HOI and 
bleaching-powder solution. (See p. 68.) 

D. Test for the Normal Inorganic Salts of the Urine. 

1. For chlorides : Take the wine-glass which has 
been used for the HN0 3 test A, and, if much albumen 
has not separated, stir up the mixture of urine and 
HN0 3 with a glass rod and add one or two drops of a 
solution of nitrate of silver (AgN0 3 ). (P. 73.) 

2. For alkaline phosphates, with the * magnesium 
fluid mixture (p. 80), after precipitating the earthy 
phosphates with KOH or NH 4 OH. 

3. For sulphates, with barium chloride (p. 82). 

F. Further Tests for Abnormal Matters. 

If it is necessary to test for the more obscure 
substances which may be present, we use the afore- 
mentioned tests for ammonium carbonate (p. 142), hy- 
drogen sulphide (p. 143), sodium carbonate (p. 145), 
and for leucine and tyrosine (p. 124). When the first 
three bodies are present, the urine is almost always 
alkaline. With ths latter two, biliary matters are gen- 
erally present. 

F. Investigation of the Sediment. 
The color and consistence of the sediment should 



ANALYSIS OF THE UBIXE. 

first be observed (whether crystalline, pulverulent, noc- 
culent, etc.), and also what is its chief constituent. 
lo this either chemically or better nricro- 
chemically and microscopically. (" Sediment," pages 
146-189. Finally, we determine the visible organ* 
ized constituents of the sediment (epithelium, cylinders, 
a, etc.) by means of the microscope. 

If the urine has been investigated in accordance 
with this scheme, it is convenient, for the beginner 
especially, to write in a concise form all that he ha3 
found, in order that he may draw his conclusions from 
a glance at the analysis. 

This form may be conveniently made by simply 
folding a sheet of paper three times (see p. 229). 

The abbreviations are as follows : 

H. 2 S0 4 test = Sulphuric-acid test for coloring matters. 



Ind 


= Indican. 


Ut 


= Urea, 


Ur 


= Uric acid. 


CI 


= Chlorides. 


E. ph. 


= Earthy phosphates. 


A. ph. 


= Alkali phosphates. 


Sul. 


= Sulphates. 



In order to express whether the constituents are 
present in normal, increased, or diminished quantity, w^e 
employ the following : 

A normal amount present is denoted by n ; a mod- 
erate increase by m -\- ; a moderate decrease by m — ; 



KEY TO APPROXIMATIVE ANALYSIS. 229 

a large increase by st -|- (strongly increased) ; a large 
decrease by st — (strongly decreased). 
The results may be arranged as follows : 



Physical Characteristics. 



Normal Substances. 

H 2 S0 4 test . CI . 

Ind " . E. ph. 

4-Ur. . . . A. ph. 

— Ur. . . . SuL. 



Abnormal Matters in Solution. 



Sediment. 



Conclusion. 



The increase and decrease is that of the percentage. 
Such a filled out table appears as the following ex- 
ample. 



A&ALYSIS OF THE UL 



Physical Characteristics. 

24-hour amount = 4,000 a 
Pale yellow. - hat tnrbi 

Sp. gr. = lv-±0. Slight ?c.lii_r:.:. 



m 



XoRMAX Matters. 

H : S0 4 test . . st — CI 

m — E. ph. . . st 

+Ur) m _ A. P h 



— Ur » 



^ pn. i 

SuL » 



m — -. * .- . st — 



Ab>" Matte::? r>- - 

Sugar in considerable quantity. 



Skddlknt. 
asts of mucus in normal quanta 
Microscopically, isc-1 _ Been. 



alt = Diabetes 



With such a blank one may write in its proper 
division the result of e it that L bom 

A to F, the presence and amount of the bu] 
found, and the conclusion he may have drawn. If we 
look at the table in the example, we cor. 

a the 24-hour amount, th - pciyu) 

- in the specific gra _ he quantity 



KEY TO APPROXIMATIVE ANALYSIS. 231 

of solid matters, diabetes ; 3d. From the pale color and 
the lack of urates, that no febrile condition exists ; 4th. 
Finally, from the amount of sugar present, diabetes mel- 
litus. 



CHAPTER VII. 

GENERAL LI A GXOSIS. 

At the time when the entire investigation of the 
urine consisted in observing the physical characteristics, 
and then only with preconceived notions, so that one 
took pains to torture the " urine signs ? ' to conformity 
with a system previously constructed on a speculative 
basis, the investigation of the urine could afford no 
essential service in the diagnosis of febrile processes, and 
not seldom afforded a cloak to ignorance and charlatanry. 

It is only since the advance of organic chemistry and 
the use of the microscope, and since the connection be- 
tween the characteristics of the urine and the tissue 
metamorphosis on the one hand, and the construction of 
the urinary apparatus on the other, has been clearly 
understood, that the investigation of the urine has dared 
to claim for itself an important character and a scientific 
value. At present no one doubts that it is essentially 
necessary for the diagnosis of disease. Moreover, in 
certain cases, from the urinary analysis alone can their 
nature, condition, and intensity be determined. It would 
be a gross error to believe that from the urine all possi 



GENERAL DIAGNOSIS. 233 

ble diseases can be diagnosed ; but it would be equally 
unjust to attempt to exclude as useless urinary investi- 
gation. 

Before we speak of the diagnosis of diseases of the 
urinary apparatus, we will mention what is important 
uroscopically with the various diseases in general. In 
this series we comprise those indications which are most 
valuable and necessary to the practicing physician. 

1. Take the twenty-four hours' amount, and consider 
if it be normal, increased, or ^am\ nished. The normal 
amount is generally 1,500 c.c. If the twenty-four hours' 
amount is considerably increased, we have to do with 
polyuria; if it is diminished considerably, with oligu- 
ria ; and, if there is no urine excreted, with anuria. 

Polyuria may be either physiological or pathological. 
In the first case it is urina potus or urina spastica; in 
the latter case, on the other hand, we have either Tiydru- 
ria or diabetes. In order to make a differential diagno- 
sis, we must calculate from the specific gravity the 
amount of solid matters excreted in twenty-four hours, 
by means of Trapp's or of Haser's coefficients (p. 39). 
If the quantity of solid matter is normal (nearly 70 
grammes) or thereabout, it is a case of urina potus ; i. e., 
as far as its solid constituents are concerned, a normal 
urine diluted with much water If the amount of solids 
is diminished, we have a liydruria to treat, which may 
occur with several cachexies. If, on the contrary, the 
solids are considerably increased, we have a diabetes. If 
with the diabetes a large amount of sugar is present, we 
have a diabetes mellitus. If, on the contrary, no sugar is 



234 ANALYSIS OF TEE URINE. 

present, we have a diabetes insipidus (by an increase of 
the nitrogenous materials, an azoturici). 

Oliguria is easy to diagnose, and occurs chiefly with 
febrile processes. The urine is generally dark-colored 
and strongly concentrated. In the latter stages of kid- 
ney diseases, after the appearance of uraemia, the amount 
constantly decreases. A slight oliguria may occur tem- 
porarily after a loss of water, as by profuse sweating or 
diarrhoea. 

Anuria with an unobstructed urethra occurs only in 
severe kidney affections, in connection with uraemia. 
Besides, this occurs with stricture, stone, and new 
growths, as so-called retention of the urine. 

If the amount of urine has been satisfactorily inves- 
tigated, we observe : 

2. Whether or no the specimen is a febrile urine. 
We may also often determine whether the febrile pro- 
cess is acute or chronic, since the acute inflammatory 
processes are usually accompanied by important febrile 
indications. 

Febrile urine has generally a dark reddish=yellow 
color, is concentrated, and its volume likewise dimin- 
ished. If, as is seldom the case, the amount of urine is 
not diminished, but on the contrary is increased, the 
coloring matters are likewise increased. We regularly 
find in fever urine a distinct layer of urates by the 
HNO, test (A). 

If an acute exudation process is present at the same 
time, the urine is concentrated, acid, and contains many 
urates, which come down upon cooling, colored by a red 



GENERAL DIAGNOSIS. 235 

coloring matter (uroerytnrine) as a rose- or tile-red sedi- 
mentum lateritium. At the same time the excretion of 
the urea, sulphates, and alkali phosphates is increased, 
while the chlorides are diminished. With an increase 
of the disease the chlorides may steadily diminish, until 
they finally disappear at the climax. 

In the stage of resorption the concentration of the 
urine gradually disappears, the reaction becomes gradu- 
ally neutral or alkaline (from carbonate of ammonia), 
the chlorides are again present in normal amount, and 
in the sediment are found urates (as urate of ammo- 
nium) and earthy phosphates. Simultaneously the urine 
may be normal in volume or somewhat increased, while 
during the exudation process it was diminished. 

Although in most cases it is not very difficult to 
diagnose from the urine an acute inflammation or a so- 
called status febrilis, we are not able to make (except- 
ing the diseases of the urinary apparatus) a differential 
diagnosis between the various forms of febrile affections. 
Even in the kidney diseases one may be so far deceived 
that, being misled by the uroscopic indications, he may 
mistake an accompanying affection for the principal dis- 
ease. For example, the urine of scarlatina is analyzed, 
and one finds a febrile state in connection with a de- 
squamative or parenchymatous nephritis. From the 
uroscopical indications we diagnose acute nephritis, al- 
though scarlatina and not nephritis is the predominant 
disease. The former could not be diagnosed from the 
urine. 

Notwithstanding that the differential diagnosis of 



236 ANALYSIS OF THE URINE. 

febrile affections is not possible, the analysis of the urine 
should not be omitted, since from it we may often deter- 
mine an advance or improvement in the condition, and 
often detect further complications. For example, the 
reappearance of the chlorides is regarded as a favorable 
sign, while the appearance of albumen is an unfavorable 
symptom. 

Among the acute febrile processes there are a few to 
be mentioned which lend characteristic peculiarities to 
the urine, and which are of essential importance to the 
physician to confirm his diagnosis. 

With icterus we constantly find biliary matters in 
the urine. 

With icterus levis, an icterus of a lighter grade, sim- 
ply a febrile state is discovered (i. e., much urates in an 
acid, dark, concentrated urine), and a rich mass of biliary 
coloring matters, the chlorides at times appearing in less 
quantity. With icterus gravis — in which the principal 
cause is not simply a resorption of the biliary constitu- 
ents, from a catarrhal affection of the ductus choledochus 
and cysticus, but much more a parenchymatous affection 
of the liver itself, often also a quick breaking down of 
the liver cells — besides a large quantity of the urates 
and biliary coloring matters, we find also albumen, and 
at the same time small amounts of the biliary acids. 
The chlorides are entirely wanting. 

With acute liver atrophy we usually find a urine rich 
in biliary coloring matter, of low specific gravity and 
acid reaction. The, urea is greatly diminished, and in 
its place we find leucine and tyrosine (the latter also as 



GENERAL DIAGNOSIS. 237 

a sediment). The chlorides have entirely disappeared. 
Moreover, urates and albumen, the latter in great amount, 
are present. Biliary acids can be proved in such urine. 
In the sediment is found a great amount of epithelial 
casts and fibrinous cylinders, besides kidney epithelium 
and isolated blood-corpuscles. 

With acute lung diseases we find a larger amount of 
urates corresponding to the insufficiency of respiration. 

With heart diseases, or irregularities of the circula- 
tion, we find a stasis in the venous system and resulting 
albuminuria (renal stasis) ; just as there occurs with 
many acute febrile diseases, and especially exanthemata, 
a kidney affection as a complication. 

With peritonitis we find usually a large amount of 
indican. (Senator.) 

The urine of meningitis is generally very strongly 
concentrated, corresponding to the slowness of the pulse. 
Since the differential diagnosis between meningitis and 
typhus is very difficult, and clinically often impossible, 
various indications may be gathered from the urine. 
Unfortunately, they are not to be entirely depended 
upon. The urine of meningitis should show a high 
specific gravity and a weakly acid reaction, and should 
contain some albumen and much urates. Besides the 
increase of the specific gravity, another characteristic 
should be that, by boiling the native urine, the earthy 
phosphates should separate (Heller's bone earths). The 
chlorides are not strongly diminished. In typhus, on 
the contrary, the specific gravity is not so high, and the 
urine is acid and should contain no so-called bone earths. 



Hi- '..'. n : — /: ■£:: :i:_ -" :■..'-—?"- \~ —-:.-> l;nnn= 
ished. Di - are present, and albumen may be found 
in larger amount. At the same time in typhus urine a 

~;nn- ;.:_ ~.:n _ : ..•.:'"■ n;n- :: ■? — —. : linm sin nil '■.-_ 
proved, the urine at the same time possessing a distinct- 

'- ;,.;:;: :-.:,.:: ;i. 

-1--- . :l^:-\:-:_-- :_•; :"_ in :.: n.n. Tlr ^e:n:: rr.-— i~ 
of this urine, in contradistinction to that of meningitis 
cerehralis r should be lower. 

With acute articular rheumatism we observe, besides 

.:. '_:."_ - r:id: n: ;--;—. in :■..//: rnn:ni:n. in ::-;:— 1 Mr-;: 
and urates, and a characteristic strong increase of earn 
-"_ .-•"_:.- — Tl-r — lim^n: =?1 "ill nnnnn V-nninn 
:>-•:- i n:;-— ;n i. . n.n;n- :: :ni;innn : :l:r-rl ~:t nno-ry- 
:*_:~i:_-r. If " -:;:;: i:~i- -nn~- il-:. ~L- :-nl;rilr- .nnl 
t.:c-"_7t1 ^ijfr- ■:_i_:~>"_ :n i ">. V.:: -'_- -.:: : r— i_:in- 
.v "--:- -::_ m :r ' r :•".:: "nr:„ 

If the urine is not colored dark reddish . and 

:~ —- --;• 

mine that no febrile process accompanies the disease. 

Among the f e verless and consequent! y for the most part 

:"_: :;:: :--::: ns. — --r-^l ;•:— — s ;-:-; : .i:: :ii.\: .• : v:>"i : 

peculiarities in the urine, which for complete! 



Chlorosis furnishes a very pale and light urine T cor- 
responding to the lessened tissue-metamorphosis in the 

_ n>:n. W-:l " --- ,' .-. ~i:..ii,: -.irir.-r ;•---,•>.'•:- 
" : -\ -n in.:-...— n -::::-- in :.:.•—. .-n 1 \ inn-: nn •;:;- 
of indican (jarina spastica). The urine of hydruria and 



GENERAL DIAGNOSIS. 239 

diabetes is also pale. How these two may be distin- 
guished from one another has been already explained. 
With diabetes mellitus the specific gravity is higher in 
spite of the increased amount. An increase of indican 
is observed by the reaction, and in the later stages of 
this disease much albumen appears. The remaining 
normal constituents are diminished in percentage, but 
the absolute amount (with the exception of uric acid) is 
increased. In saccharine urine very many and beautiful 
yeast plants are found in the sediment, as well as net- 
works of penicillium. 

With chronic diseases of the spinal cord often occurs 
a pale and light urine, which besides much indican and 
bone earths contains a very small quantity of sugar (?). 
In the sediment Heller claims to have often observed 
sarcinse. 

With rachitis, and especially with osteomalacia, the 
earthy phosphates are strongly increased, so that they 
form a copious sediment. 

With diseases of the lone, especially if a great part 
of the skeleton is involved, we find an increase of car- 
bonate as well as oxalate of lime in the sediment, to- 
gether with the so-called bone earths, partly in solution 
and partly in the sediment. 

With chronic articular rheumatism is found a 
strongly acid, concentrated urine, which contains a 
sediment rich in urates and calcium oxalate. A great 
increase of earthy phosphates is characteristic. 

In gout we find a similar urine, except that the uric 
acid is excreted in less amount, and is therefore retained 



240 THE UEIXE. 

in the _ .nism. At times a beautifully crystaL. 
sediment of free uric acid is found. 

In in the cold stage, the excretion 

of urine is inc: md it is light and clear, while in 

the h _ .ark and satura' 

In in sj :te of the fact that 

no fever exists, we find a dark, acid, concentrated urine. 

m] res- 

: the normal cr. i _ matters are ~: ngfy increased 

(de \ and indican reaction); and generally 

uroeiythrine is also present This increase of the color- 

matteis of the urine is accounted for by an incre: 
exchange md o.retion of biliary coloring mat::- 
earthy ph soaBy diminished. In the 

ieu — - rind frequently ura* e -red by 

uroeiythrine, and many tin o^all amount of calcium 

oxalate. 

ially in those affections 
wh: the function of perspiration. 

find regularly at: - a complication ; i 

pemphii 

we fre- 
quently find haemorrhage from the kidn • in 
. with which we usually have parenchyma- 

Witfa ! / the urine is rich in uric acid, and 

often al- lactic m ur. 



CHAPTER Vin. . 

DIAGNOSIS OF TEE DISEASES OF THE URINARY 
APPARATUS. 

If urine which contains neither pus nor blood, nor 
has been accidentally mixed with albuminous fluids, 
shows the albumen reaction, this condition is called true 
albuminuria ; and disease of the kidney itself is indi- 
cated. If, on the contrary, albumen is present only as 
blood or pus, the condition is called false albuminuria, 
and is usually a symptom of an affection of the kidney- 
pelvis, ureters, or bladder. Mixed albuminuria is when 
there is more albumen in the urine than can be ac- 
counted for by the presence of blood and pus. 

Whether, in addition to the amount contained in 
blood and pus, albumen in other forms is present in the 
urine, can only be accurately determined by one very 
familiar with the albumen reaction, and sometimes even 
he will find it quite difficult. The best way of learning 
to distinguish false from mixed albuminuria is to add to 
normal urine the so-called healthy pus of a suppurating 
wound, and, after allowing the sediment to form, apply 
the test for albumen. 

16 



MKB - AL AXI» CHEMICAL AD ~ DIAGNOSIS OF 

P ATP, T~MTM Hl\, 

A. Thte A iak 

L Hypertonia of Ike Kid 

srestion caused unusual im- 

D nneu k : und in the urine. The daily 
e ts increase I, its lor bee mes le yel- 
- the s| seine gn 

low, and the normal solid constituents are usually - :• 
greater quan~i 

othjie present in urine when 
■ cons: he Id Ineys 

- | earl 1 1 ^ then f I i : 

dia~ is. It ak :nall 

- . and gi ly even less 

from hvpersemia of the kidney rased irri- 

xcreted 1 for 

- - a I he loi . . • i .tinned internal use of balsam 
eopaivae, turpentine, eubehe -ublimate. and 

i acrid _ 

A _ --'nition of the urine 

id also a "hat 

is, h 1 1 k -veil hx t a 

I urine may give rif ani- 

_an, and may sometimes even 
_ ht albuminuria, which is. how 
trai> 

Partly from chemical and partly from mechanical 



DISEASES OF THE URINARY APPARATUS. 243 

irritation, as by oxaluria and excessive amount of uric 
acid in the mine, especially if this fluid has a strongly 
acid reaction and the uric-acid crystals are pointed or 
jagged, a mild albuminuria may be produced. This can 
however be easily cured, if one pays attention to the 
character of the urine, and induces the patient to drink 
a great amount of water ; for by this means the solids 
of the urine, especially the alkali-salts, are excreted in 
greater quantity, which, besides neutralizing the acidity 
of the urine, are excellent solvents of the uric and oxalic- 
acid crystals. 

The crystals of uric acid, in addition to their irri- 
tative action, not infrequently become kernels for the 
formation of renal calculi. 

Further, a slight temporary albuminuria is observed 
after convulsions, epileptic and intermittent fever pa- 
roxysms, and various other forms of vascular contrac- 
tion. It also frequently occurs in conjunction with 
acute fevers (Bart els' febrile albuminuria), especially 
with acute exanthemata, and finally sometimes with 
inflammatory affections of the skin, as anthrax, furun- 
culosis, erysipelas, burns, etc. Often by hyperemia of 
the kidney, if the primary disease advances, a parenchy- 
matous inflammation is introduced. 

From passive hypersemia of the kidney, a result of 
general venous sluggishness, the albuminuria increases 
or diminishes in proportion to the more or less complete 
venous stasis. 

Often a retardation of the renal circulation results 
from feebleness of the heart's action. If, however, in 



244 ANALYSIS OF THE UBWE. 

such cases the normal blood-pressure is restored by- 
proper medicines, the albuminuria usually disappears. 
The renal circulation is also impaired by chronic pul- 
monary diseases, especially emphysema, and by all tu- 
mors and exudations which retard the general current of 
the venous blood ; as, for example, large pleuritic effu- 
sions, ascites, ovarian cysts, and advanced pregnancy. 
Puerperal eclampsia is not alone accompanied by a tran- 
sitory renal venous stasis (Rosenstein), but veiy fre- 
quently also by parenchymatous nephritis (Bartels). 

As a consequence of marasmus and with various 
cachexies, a hyperaemic condition of the kidney is ob- 
served. 

The characteristics of simple hyperemia of the kid- 
ney are that the specific gravity of the urine is generally 
though not always high, the amount is diminished, or 
else normal in quantity, and the reaction is acid. Al- 
bumen appears in small quantity (one tenth per cent, 
or even less). In the sediment either no organized ele- 
ments are found, or at most single blood-corpuscles and 
epithelial cells from the straight tubules ; hyaline casts 
are scarcely ever seen. 

In febrile albuminuria, in addition to this, the 
quantity of the urates is increased, while that of the 
chlorides is greatly diminished. 

In stasis of the renal circulation proper, the twenty- 
four hours' amount of the urine is always diminished, 
the specific gravity is high, the color dark, and the reac- 
tion acid. This urine contains a large amount of urates, 
which frequently render it turbid, and settle down as a 



DISEASES OF TEE URINARY APPARATUS. 245 

copious sediment. About one fifth per cent, or more of 
albumen is present. In the sediment are usually found 
hyaline casts and single cells of kidney epithelium. 

This renal stasis is distinguished from parenchyma- 
tous nephritis by the absence of cellular forms (blood- 
and lymph-corpuscles, granular epithelium from the 
kidney) and of granular casts in the sediment of the 
urine. 

The urine accompanying renal stasis is distinguished 
from that of chronic interstitial nephritis (cirrhosis of 
the kidney), and that of the "waxy" kidney, by its 
dark color, its high specific gravity, its small amount 
during the twenty-four hours, and the abundance of 
its urates. 

2. Parenchymatous Nephritis. 

Two forms of parenchymatous nephritis are ac- 
cepted — acute and chronic. The acute form usually 
occurs as a sequence of other acute diseases, and is sel- 
dom primary ; while the chronic, the so-called second 
stage of Bright's disease, is generally primary, and sel- 
dom follows the acute form. 

a. Acute Parenchymatous Nephritis. 

Of acute parenchymatous nephritis two forms are to 
be recognized. One is a slight affection, the so-called 
catarrh of the urinary tubules, or desquamative ne- 
phritis ; the other a more severe form, the acute paren- 
chymatous nephritis proper (diffuse or croupous), the 
so-called acute Bright's disease. 



ANALYSIS 

nchyma - in most cast.- allows 

a favorable | _ sis. Only in those eases where there 
snppj ssion of the minary secretion 
( anuria ) is there usually a fatal teiToinatioiL De- 
squamative nephritis always inns a ice 

a. ' of ike or desquamative 

" ">. — This form pre: i an eots the straight 

tubules. It lasts from eight to fourteen days, but often 

a still si dine. Fever is essential charaeter- 

Those afiected complain <:»f s tidiness in their 

joints, pain in the region of the sacrum, and general 

They frequently walk about during the 

whole f the disease. (Edema seldom occurs. 

The urine shows the following characteristics : 

The twenty-four hours" amount is either no:m 
alightly diminished: the is true of its specific 

gravity. The color is wine-yellow, - in y yel- 

low : th is acid. I - 

turbid by the presence n enhha: Ov.irs. :.-d s methnes 
aits a thick sediment. 

The normal coi 1 in normal pro- 

portion. 

Of abnormal substances, albumen is found in mod- 
erate quantity, one tenth to one fifth per cent., and some- 
time blood-coloring matter. 

The sediment i a chiefly of an increased am >unt 

of muc- .. Mic - aroufl 

epithelial cells from _it tubules, which are 

Bometam >wn by the coloring matter of the 

blood They are frequently 1 bed together in the 



I 

DISEASES OF THE URINARY APPARATUS. 247 

form of hollow cylinders, being known as epithelial 
casts ; or the epithelial cells may form the covering of a 
hyaline cylinder (both together forming the epithelial 
cylinders). (PL VII., A., 5.) In addition are found 
isolated hyaline cylinders, red blood-corpuscles, and a 
somewhat larger number of lymph-corpuscles. 

Inflammation of the straight tubules also results from 
the introduction of instruments after catheterization of a 
sensitive bladder, dilatation of strictures, introduction 
of the lithotrite, etc. It also accompanies acute inflam- 
matory processes, especially the exanthemata. 

Ex contiguo, desquamative nephritis arises from 
inflammation of the bladder caused by the retention of 
urine after gonorrhoea. 

The higher degree of this affection is — 

0. Acute parenchymatous nephritis proper. — This 
disease may occur with very severe disturbances, and 
also without noteworthy subjective symptoms. The 
latter condition is observed in reduced cachectic indi- 
viduals. 

The important symptom, which first causes the pa- 
tient as well as the physician alarm, is dropsy. This 
appears especially characteristic as oedema of the face, 
which produces a bloated appearance. Severe cases are 
accompanied by anuria and convulsions. The less the 
twenty-four hours' amount of urine, so much the more 
severe generally becomes the disease ; so that with an 
anuria of long duration the disease usually proves fatal. 

The urine shows the following changes : 

The twenty-four hours' amount is greatly diminished, 



•24S ANALYSIS OF THE UEIXE. 

often to 250 c.c. The specific gravity is usually in- 
creased ; the reaction is acid, and the urine has a brown- 
yellow, dirty color, being quite turbid from the presence 
of many cell elements. The latter after long standing 
settle as a considerable sediment. 

The normal constituents are excreted in diminished 
amount. 

Of the abnormal matters, we find serum-albumen in 
sreat amount, and at times blood-coloring matters also 
in considerable quantity. Albumen comes in from 1 to 
5 or 6 per cent., so that the urine is transformed by boil- 
ing to a thick jelly. 

The sediment is generally colored brownish, and 
consists principally of a thick mass, often colored brown 
by blood-coloring matters, at times of long corkscrew- 
twisted fibrine-cylinders, containing often a great amount 
of lymph- or red blood-corpuscles (blood-cylinders) or 
adhering brown-colored (hemorrhagic) epithelium of 
the urinary canals. In other cases we find only cell 
remnants surrounding distinctly visible nuclei, which 
are in part contained within and in part on the surface 
of the cylinder. Besides, many isolated epithelial cells 
froni the tubules are found, together with many blood- 
and lymph-corpuscles, and a mass of molecular detritus, 
richly colored brown from the blood-coloring matters. 

Acute parenchymatous nephritis either develops it- 
self primarily, or it occurs as a consequence of another 
acute disease. It appears especially frequent after acute 

iithematous affections, namely, after scarlatina, and 
.uence of diphtheritis, febris recurrens, phleg- 



DISEASES OF THE URINARY APPARATUS. 249 

mon, erysipelas and carbuncle, after employment of 
preparations of which cantharides may be taken as the 
type, and also after the internal exhibition of violent 
and caustically acting medicaments, as corrosive sub- 
limate. 

It is frequently observed after taking cold, and after 
burns of wide extent on the skin. After articular rheu- 
matism, in cholera, and in pregnancy it appears fre- 
quently as a complication. 

Finally, acute nephritis occurs frequently in the 
course of chronic parenchymatous nephritis. 

Although the prognosis in most cases of this disease, 
even if it has lasted several weeks or months, is favor- 
able, yet in single severe cases, with the appearance of 
acute uraemia, the fatal end may come in a few days. 
On the other hand, the acute form may pass over to the 
chronic. 

b. Chronic Parenchymatous Nephritis. 

The first symptom of this disease is also dropsy. 
Fever is not present. 

The urine shows the following changes : 

As long as chronic nephritis advances, or while the 
disease remains at its height, the twenty-four hours' 
amount is diminished ; but as soon as the chronic nephri- 
tis retrogrades, the amount of urine increases, and in the 
stage of the so-called kidney atrophy it may pass beyond 
the normal amount. 

The color of the urine is dirty yellow, often brown- 



OF THE CRIXE. 

yellow. It is I :'rom numerous cell forms, which, 

after settling show a ma< sediment 

The reaction is acid, and the specific gravity is usually 

:ed. 

normal constituents (especially urea) are ex- 
creted in diminished quantity. 

Of the abnormal substances, albumen is found from 
one half to one or two per cent. Blood-coloring matters 
are present ; at least, traces are provable, 

In the sediment we find at times in large amount, 
but usually isolated, dark nucleated granular cylinders, 
or half granulated, made up of a hyaline ground-sub- 
stance with insulated granular ma- — - sparingly dis- 
tributed over its surface. (PL VII., A. 2.) There are 
found nucleated granular kidney epithelium and 

_!e blood- and lymph-corpuscles, with molecular de- 
t ru- 
in the condition of secondary atrophy the twenty -f our 
hours' amount is considerably increased. The specific 
g ra v ity is much lowered. The color is pale yellow. 
The urine is also turbid, and shows a macroscopically 
visible sediment. 

The excretion of the Dormal constituents, especially 
the urea, when the atrophy affects both kidney-, is 
greatly diminished. 

Albumen i at in only small amount (one tenth 

to one fifth per cent.). 

In the sediment we find granular mi istmg 

of < _:aiiular kidney epithelium, and isolated 

"f granular cylinders. 



DISEASES OF THE URINARY APPARATUS. 251 

This disease occurs in a minority of cases as a 
sequence of the acute nephritis, but generally it has 
other modes of origin. 

Chronic parenchymatous nephritis arises from the 
acute parenchymatous nephritis, though most frequently 
after scarlatina, after severe rheumatic processes, after 
profuse bone suppuration, and also from the nephritis of 
pregnancy. 

Parenchymatous nephritis originates in the chronic 
form after purulent osseous and articular inflammations 
in consequence of intractable syphilis, pulmonary phthi- 
sis, malaria, scrophulosis, and other cachexies ; also from 
the immoderate use of spirituous liquors, which is of 
especial importance. 

The prognosis is not very favorable. There are 
indeed cases in which, after years of a dropsical and 
albuminurious condition, recovery has taken place, 
though this termination is not the usual one. After 
syphilis and malaria we may by energetic treatment 
secure healing, and also after a profuse osseous suppura- 
tion, when the contained pus has been gotten rid of sur- 
gically. 

3. Interstitial Nephritis. 

The interstitial connective tissue of the kidney may 
be altered either by hyperplastic growth or by destruc- 
tive suppuration. Accordingly we distinguish two 
forms of this disease, the hyperplastic interstitial ne- 
phritis and the suppurative interstitial nephritis. 



252 ANALYSIS OF THE URINE. 

a. Hyperplastic Interstitial Nephritis — Cirrhosis of the 
Kidney — Genuine Kidney Atrophy. 

This affection occurs most frequently in advanced 
life, very seldom in youth. 

Cirrhosis may have existed for a long time, and may 
have attained a high grade, without the patient having 
by any symptom whatever suspected any disease of the 
kidney. Dropsy occurs not at all, or only in the last 
stages. 

A tense and quick pulse and a hypertrophy of the 
left ventricle are the usual symptoms of this form of 
disease of the kidneys. 

Disturbances of vision complicate especially this 
form of the kidney diseases, and are not seldom 
the first symptom for which the physician is sum- 
moned. 

The urine shows the following conditions : 

The external appearance after excretion is similar to 
that of normal urine. It is bright and clear, and shows 
sometimes a darker, sometimes a lighter color, corre- 
sponding to its concentration. The twenty -four hours' 
amount is generally increased, though polyuria is not 
always the rule. The specific gravity is either normal 
or more frequently lowered. The reaction is acid. 

The normal constituents are usually excreted in 
normal mass. 

Of the abnormal constituents, albumen is found in 
moderate amount (0*1, 0*2, 0*5 per cent.). It may also 
entirely disappear from the urine. This happens espe- 



DISEASES OF THE URINARY APPARATUS. 253 

cially in a condition of perfect rest; hence more is 
found in the day than in the night urine. 

Macroscopically we do not observe a sediment after 
long standing. Usually we find nothing abnormal by 
our microscopic investigation. Only at times, when 
after long standing we pour off all but the last drop of 
the urine, and then examine this thoroughly by the 
microscope, we find a hyaline cylinder, a blood-cor- 
puscle, or a little changed kidney epithelium. 

The prognosis of this disease, if the diagnosis is cor- 
rect, is an unfavorable one, though the course of the 
disease may be long. 

The aetiology is obscure. 

b. Su/ppurative Interstitial Nephritis. 

This may be of traumatic, idiopathic, pyaemic, or 
metastatic origin. It often proceeds from chronic 
pyelitis, when the disease of the pelvis extends to the 
connective tissue of the kidney and sets up suppuration. 
It is this usually which, after surgical interference with 
the urinary organs, closes the scene. Suppurative 
nephritis occurs in this way, after catheterization of a 
paralyzed bladder, after forcible dilatation of strictures, 
and after lithotrity. It was on this account that this 
disease was formerly known as surgical kidney. 

Kidney calculi predispose especially to suppurative 
nephritis, and that complicated with great kidney ab- 
scesses and pyonephrosis. 

The urine shows the following conditions : 



ALY8I& THE UBINR 

It has a dirty yellow color, is cloudy, and is passed 
in small quantity. The odor is putrid. The specific 

gravity is diminished, the reaction being usually neutral 
or alkaline. 

The normal constituents, especially urea, are ex- 

d m diminished quantity. 
Of the abnormal constituents, albumen is present in 
greater ma-- [ t 1 per cent/). Blood-coloring matters 
are usually present. Not seldom carbonate of ammo- 
nium and ammonium-sulphide are present in greater 
quantity. 

The sediment is considerable, and consists chiefly of 
ulent pus mixed with blood in greater or smaller 
amount. Micr lly are found, besides numerous 

bacteria, molecular detritus and kidney epithelium, and 
seldom beautifully formed, thick, often-branched 
cylinders, which are formed of bacteria | pyelo-nephritis 
parasitica, KLebs). If it i ted with parenchy- 

matous nephritis, we rind also dark, granulated, mostly 
thick cylinders from th< sjht tubules. 

The is usually acut- — generally 

ally. In chronic . abe sses dis- 

charg the pel 1 he kidr 

We can oi - kidney aba esses I y i stimat- 

ing the amount of | reted per diem, which we can 

lo with gradual - A suddenly ap- 

I then ring amount - in the 

urine, t< I evidences of broken- 

d kidm glomeruli, tubulee furnish the 

for the 



DISEASES OF THE URINARY APPARATUS. 255 

4. Amyloid Kidney. 

Amyloid degeneration of the kidney is generally a 
local manifestation of a constitutional disease. It occurs 
therefore frequently in connection with extended osseous 
suppuration, as well also as with other long continuing 
and profuse suppurations. With pyonephrosis on one 
side, not seldom the other kidney becomes amyloid. 
Scrophulosis, chronic tuberculosis, and obstinate syphilis, 
and at times also malarial cachexy, favor especially amy- 
loid degeneration of the kidney. In rare cases this 
affection is due simply to disturbance of nutrition. Fre- 
quently it is complicated with parenchymatous nephritis. 

The amyloid disease of the kidney is developed quite 
insidiously and without marked symptoms, though as a 
rule the amyloid kidney excretes a larger amount of 
urine in twenty-four hours than the healthy kidney in 
the same space of time. This excess is never so great, 
however, as is usually found in general atrophy of the 
kidney. 

The urine shows the following conditions : 

It is pale yellow, clear, and has a low specific gravity 
and acid reaction, and deposits no visible macroscopic 
sediment. 

The normal constituents are generally excreted in 
diminished amount. 

Of the abnormal matters, serum-albumen is present 
in moderate quantity (from 0*1 to 1-2 per cent.). Be- 
sides serum-albumen, we often find globuline in rela- 
tively considerable mass (Senator, Edlefsen), which may 



•256 ANALYSIS OF THE UPJXE. 

be regarded in each cases as characteristic of this dis- 

In the sediment, seldom visible inacroseopically, are 
found generally no cell-elements, but sometimes narrow 
hyaline, or also broader waxy, glistening, fragile, yellow- 
colored cylinders. (PL VIL. A. -i.) Occasionally we 
observe brightly glistening, amyloid, degenerated kidney 
epithelium, which, in the same manner as the waxy 
cylinder, is colored reddish brown by a watery solution 
of iodine, and further upon addition of sulphuric acid a 
dirty violet color. Blood does not appear in the sedi- 
ment with pore amyloid kidney. 

The prognosis depends upon the constitutional dis- 
ease. If one has to do with syphilis and malaria, favor- 
able response to treatment may be expected. 

In the different forms vf 

allv < mini/ ria, the following points are to be observed: 

1. If already in the mine a macroscopically visible 
sediment is present, consisting of a great mass of cell- 
elements (blood-corpus ] a, pus-corpuscles, cylinders, 
etc.), we have to do either with parenchymatous or sup- 
purative in st erst it ial nephri 

a. In j we find in the sedi- 

ment epithelial, fibrinous, and granular cylinders, kidney 
epithelium, and blood- and lymph-corpus* 

I. I we find in 

the sediment blood- and ; much bacteria, 

and someti rian cylin abort and 

thick darkly nun onlar cylinders. 



DISEASES OF THE URINARY APPARATUS. 257 

2. If the urine is clear or only clouded by urates, 
and no sediment is discovered which consists of a con- 
siderable mass of cell-elements, then we have to do with 
renal stasis, or with a hyperplastic interstitial nephritis, 
or with an amyloid kidney. 

a. Renal stasis is distinguished from both the other 
diseases of the kidney by a decrease in the twenty-four 
hours' amount of urine, by its dark color and high speci- 
fic gravity, and often by the abundance of urates. The 
amyloid kidney and the hyperplastic interstitial nephri- 
tis are characterized by an increase of the amount of 
urine ; also in both diseases the urine is bright and 
clear, of pale yellow color and low specific grav- 
ity. 

b. Amyloid kidney differs from interstitial nephritis 
in that the urine contains globuline, and by the presence 
of waxy cylinders and amyloid degenerated kidney epi- 
thelium. 

Clinically we very constantly find with amyloid kid- 
ney (as with parenchymatous nephritis) dropsy, while 
with genuine atrophy this occurs seldom, and if at all in 
the latter stages. 

In genuine Mdney atrophy is found constantly hy- 
pertrophy of the heart and a quickened pulse, while 
these do not occur in parenchymatous nephritis and 
with amyloid kidney. 

Finally, with amyloid kidney usually there is an 
enlargement (amyloid degeneration) of the liver and 
the spleen. 

IT 



258 ANALYSIS OF THE URINE. 

B. Forms of Mixed Albuminuria. 

Mixed albuminuria is recognized from the fact that 
there is more albumen present than corresponds to the 
amount of pus in the sediment. It includes those dis- 
eases of the kidney-pelvis which in advanced stages in- 
volve the kidney-structure, and thereby complicate the 
pyorrhoea with true albuminuria. 

The kidney-pelvis is limited toward the kidney by 
the calices and the papillae renales. It is therefore easy 
to understand how with extended inflammation of the 
kidney-pelvis the neighboring papillary part may be- 
come involved. A proof that the papillary part of the 
kidney has become involved by the pyelitic process, is 
the presence of kidney-epithelium in the sediment. One 
also finds in long-continued suppurative processes in the 
pelvis of the kidney, that the same is enlarged at the 
expense of the papillary part, the latter being more or 
less consumed. 

1. Pyelitis. 

Pyelitis is often a local manifestation of an acute 
febrile process ; it not infrequently accompanies paren- 
chymatous nephritis and (in advanced stages) diabetes 
mellitus. The use of copaiva balsam, cubebs, and simi- 
lar powerful medicaments, sometimes has this disease 
as a consequence. Kidney-stones, parasites, new growths, 
and tuberculosis of the kidney-pelvis are almost always 
accompanied by suppurative pyelitis. From contiguity, 
either this or pyelo-nephritis is developed by the dam- 
ming back of the urine in prostatic hypertrophy, para- 



DISEASES OF TEE URINARY APPARATUS. 259 

lysis of the bladder, stricture of the urethra, etc., pro- 
vided at the same time a purulent bladder-catarrh is 
present. Pyelitis also frequently arises from compres- 
sion of the ureters by tumors, large exudations, or a 
retroflected or pregnant uterus. Finally, it may occur 
also after maltreatment of gonorrhoea, or mechanical 
injuries to the neck of the bladder and the bladder 
proper with surgical instruments, etc. 

We may distinguish an acute and a chronic pyelitis. 
Not infrequently the sediment of the urine furnishes 
means for the diagnosis of pyelitis calculosa and tuber- 
culosa. 

The constitutional diseases which bring about pye- 
litis croup osa and diphtheritica are so severe in them- 
selves that they obscure the symptoms of the pyelitis. 

a. Acute pyelitis. 

The clearest form of acute pyelitis occurs after sur- 
gical interference with the urinary organs, in the course 
of acute inflammatory processes, and after improper 
treatment of gonorrhoea. 

The twenty -four hours' amount is diminished ; the 
urine is dark-colored and turbid, and has a high specific 
gravity and an acid reaction. After standing, a distinct- 
ly visible precipitate appears. 

The excretion of normal matters is not essentially 
changed ; it shows in a high degree the peculiar char- 
acteristics of a febrile process (the urates considerable, 
the chlorides diminished). 



260 ANALYSIS OF TEE URINE. 

Of the abnormal constituents, albumen occurs always 
in far greater amount than corresponds to the slight pus 
sediment. The percentage of the albumen varies from 
0*1 to 0*5 and thereabouts. Blood-coloring matters are 
in small amount, and not constantly present. 

The sediment consists chiefly of an increased (cloudy) 
mucous secretion, mixed with pus in less or greater 
amount. Microscopically, we find pus-corpuscles of 
round, spherical form, and often many adhere together, 
forming a cylindrical plug. These cylindrical plugs 
arise from the papillae renales, and contain not seldom 
beautiful kidney-epithelium. We always find blood- 
corpuscles, but at times only singly. The epithelium of 
the papillary part of the kidney appears in great amount 
in oval or pear-shaped forms. Often two or three 
epithelial cells hang together. We also find at times, 
though seldom, these epithelial cells colored reddish 
brown by the blood-coloring matters, which with the 
colorless pus-cells and the yellow blood-corpuscles make 
up a beautiful picture under the microscope. 

The so-called single and double caudate epithelium, 
with tile-form arrangement, which is generally desig- 
nated as pelvis-epithelium, is not a characteristic of pye- 
litis. The epithelium of the kidney-pelvis does not 
differ essentially from the epithelium of the bladder, 
which appears also in the urinary sediment of pyelitis ; 
and on this account only the epithelium of the papil- 
lary part is a characteristic for the diagnosis of pye- 
litis. 

With acute pyelitis kidney-epithelium occurs in 



DISEASES OF THE URWABY APPARATUS. 261 

greater amount, often ten pieces in the field, while with 
chronic pyelitis it appears very sparingly, 

Acute pyelitis, if it occurs in consequence of surgical 
interference in the bladder, or following acute inflam- 
matory processes, or with gonorrhoea, allows of a favor- 
able prognosis, since in the course of a few weeks heal- 
ing is apt to occur. Sometimes, however, there arises 
from the acute form — 

b. Chronic Pyelitis. 

In chronic pyelitis the twenty-four hours' amount of 
urine is increased. For this reason polyuria may be re- 
garded as a characteristic symptom. In severe cases, not 
infrequently 5 to 6 litres are evacuated in the twenty- 
four hours. The color of the whey-turbid urine is pale 
straw-yellow, and has at times a peculiar tendency 
toward greenish-yellow. The specific gravity is always 
low and the reaction acid. The sediment is more or 
less copious, corresponding to the amount of pus. 

The absolute amount of normal constituents is not 
essentially changed, but their percentage appears to be 
diminished on account of the polyuria. 

Of the abnormal constituents, albumen appears con- 
stantly in greater amount than corresponds to the con- 
tained purulent sediment. The mass of albumen is 
generally Ol to 0*5 per cent. Blood-coloring matters 
are usually not present. 

The sediment has a greenish-yellow color, is floccu- 
lent, consists chiefly of pus, and does nqt stick to the 



262 ANALYSIS OF THE URINE. 

glass. The pus-corpuscles with long-continued pyelitis 
are often branched or have tooth-like projections, unlike 
the pus-corpuscles of other acute purulent catarrhs of 
the urinary passages. They also form, since they are 
pressed together in greater mass, roundish, oval, or even 
long plugs (purulent plugs of the ductus papillares), 
which are characteristic of chronic pyelitis. (PL VII,, 
B, 2 and 4.) 

Epithelial cells are very sparingly present in chronic 
pyelitis ; and if the suppuration is very severe, they 
may be entirely wanting, since they apparently by endo- 
genous cell-formation break up into pus-corpuscles. 

Blood-corpuscles do not occur with the common 
chronic pyelitis. With pyelitis in consequence of renal 
calculi, tuberculosis, new growths, and entozoa in the 
kidney, they are, however, of constant occurrence. 

Chronic pyelitis only seldom admits of a favorable 
prognosis. In our latitudes it is usually complicated 
with primary or even (in consequence of suppuration) 
secondary stone-formation. Not infrequently it passes 
over into pyonephrosis, later perinephritis, with final 
discharge of the purulent contents toward the outer sur- 
face of the body, less often into the bladder or intestines. 
This happens usually in young or strong individuals. 
In weak or old patients chronic pyelitis passes over into 
interstitial suppurative nephritis, and chronic ursemia 
closes the scene. „ 

c. Pyelitis Calculosa. 
Calculosis^renalis is chiefly introduced by a deposit 



DISEASES OF THE URINARY APPARATUS. 263 

of uric acid within the kidney or the kidney-pelvis. 
Therefore the spontaneously arising kidney concretions, 
for the most part, are composed of uric acid or its salts, 
and have a yellowish-brown color. In addition, renal 
calculi may be introduced by excretion of cystine (most 
infrequent), and by excretion of earthy phosphates, as 
the so-called secondary stone-formation in the kidney- 
pelvis, in consequence of haemorrhage and long-continued 
suppuration. Oxalate of calcium only very rarely is 
the primary cause of stone-building; it plays its part 
later in the layer formation. 

The most frequent cause of the formation of kidney- 
stone, as we have before mentioned, is the excretion of 
crystalline uric acid within the kidney, in consequence 
of its absolute or relative (through concentration of the 
urine) excess. Naturally the concentration and the in- 
creased acidity thereby produced furnish favorable con- 
ditions for the f onnation of the characteristic rough or 
pointed crystals of uric acid, which are almost constantly 
the foundation of kidney-stones (Ultzmann, " Ueber 
Harnsteinbildung," in "Wiener Klinik," 1875, No. 5). 
Therefore the indications of kidney-stone must be looked 
for in a concentrated, acid urine, rich in uric acid, espe- 
cially if the same is excreted in jagged or pointed 
forms. 

The beginning of kidney-calculi can be diagnosed if, 
in connection with the above-mentioned conditions of 
the urine, a light albuminuria (hyperseinic condition of 
the kidney) is observed, and a few blood-corpuscles 
appear in the sediment. 



264 ANALYSIS OF THE URINE. 

The accompanying albuminuria is only temporary, 
and appears, usually, only with a considerable concen- 
tration of the urine or with a great excess of uric 
acid. 

The presence of large concretions in the kidney may 
be diagnosed from the occurrence of a parenchymatous 
haemorrhage. The urine from the before described 
chemical constitution shows, especially after violent bod- 
ily exercise, a red-brown or coffee-colored tinge. 

If the concretions do not disappear after such a 
strong kidney -haemorrhage, there arises gradually a pye- 
litis — the pyelitis calculosa. This may occur in two 
forms, a light and a severe. 

The light form occurs generally with kidney-concre- 
tions of small size, and characteristic indications are 
often offered by the sediment ; while the more severe 
purulent form differs from the ordinary pyelitis chronica, 
in that we constantly find blood-corpuscles in the sedi- 
ment. The latter form of pyelitis calculosa occurs gen- 
erally with greater concretions, and affords later a ter- 
mination for pyonephrosis and paranephritis with dis- 
charge of purulent matter. 

The lighter form of pyelitis calculosa shows the fol- 
lowing characteristics of the urine : 

The twenty -four hours' amount is not increased, but 
rather diminished, or more commonly normal. The 
urine is dark-colored and turbid ; its specific gravity 
normal or raised ; the reaction acid ; and often there is 
considerable sediment. 

Of the normal constituents, uric acid is in excess 



DISEASES OF TEE URINARY APPARATUS. 265 

(presence of crystalline uric acid in the sediment and 
proof of a layer of urates by the HN0 3 test). 

Of the abnormal constituents, we find albumen in 
from O'l to 0*5 per cent., always more than corresponds 
to the pus and blood in the urine. Also blood-coloring 
matters are constant, though they may be present in very 
small amount. 

The sediment consists chiefly of pointed uric-acid 
crystals, cystine and calcium oxalate, mixed with floc- 
culent pus in greater or less quantity. (PL II., B.) 
Besides these, numerous blood-corpuscles (microcytes) 
and kidney-epithelium cells are visible. 

The symptoms enumerated and the negative results 
from sounding the bladder confirm the diagnosis. 

Pyelitis calculosa admits of a favorable prognosis 
only with concretions of small size, i.e., such as may 
pass through the ureters. With large and branching 
concretions, the prognosis is always unfavorable, or at 
least very dubious. The more severe the suppuration 
and the longer its duration, the more unfavorable the 
prognosis. 

The disease affects usually only one kidney. 

d. Pyelitis Tuberculosa. 

Pyelitis tuberculosa is usually a local expression of a 
general tuberculosis, or a tuberculosis of the genito- 
urinary apparatus. It is on this account not seldom 
complicated with the appearance of a chronic parenchy- 
matous disease of the kidney (nephrophthisis, nephritis 



266 OF THE UBINK 

ulct- In thr.it- cases where tuberculosis of the 

kidney-pelvis implicated with tuberculosis of the 

kidney, we find in the sediment large, waxy, shining 
cylinders, much molecular detritus, blood- and pus- 
cor] and kidney -epithelium. The urine contains 

_e amount of albumen. 
Simple pyelitis tuberculosa shows, on the contrary, 

the following conditio!:- : 

_ 

The amount of the mine is not especially increased. 
The color is dirty yellow, often brown-red from admix- 
ture of blood. It appears always turbid, and has a 
normal or diminished specific gravity and an acid reac- 
tion. The sediment is dirty yellow, often brownish and 
nocculent. 

The excretion of normal constituents is not essen- 
tially altered. 

Of the abnormal constituents, albumen is found in 
from 0*1 to 0*5 per cent., always far in excess of the 
corresponding pus and blood in the sediment. Blood- 

ring matters are likewise provable in small amount. 

The sediment is brownish, nocculent, and consists 
chiefly of pus mixed with a small amount of blood. 
Beei ~. we find kidney-epithelium and much mole- 

cular detritus mixed with bacteria, which are clotted 
_ ther in spherical and cylindrical shapes. 

The bl "i the sediment are generally 

the expression of an ulcerative process in the kidney- 
pelvis, and appear in the night as well as the day urine 
in slightly varying amount ; while in pyelitis calcolosa 
the aril 1 in the night or after bodily rest shows 



DISEASES OF TEE URINARY APPARATUS. 267 

an appreciable diminution in the amount of blood-cor- 
puscles. The passage of urine with pyelitis tuberculosa 
is not so painful, nor is micturition so frequent, as in 
pyelitis calculosa. Besides this, the usual symptoms of 
lithiasis are wanting. 

Especially supported is the diagnosis of pyelitis 
tuberculosa, if one finds, without other assignable cause, 
swelling of the testicles with tense plastic exudation, 
scrofulous scars, swelling of the glands or other than 
the scrofulous osseous inflammations, and deep and diffi- 
cultly healing rectal fistulse, etc. 

The prognosis is in every case unfavorable when 
there is accompanying tuberculosis. With tuberculosis 
of the genital apparatus, if it occurs in healthy and 
young individuals, there may be improvement, or even 
(for instance, after the extirpation of a tuberculous tes- 
ticle) a relative cure. 

With echinococci in the kidney we find at times an 
accompanying pyelitis, which can not be distinguished 
from the usual chronic form. Only when the echino- 
coccal tumor has perforated the kidney-pelvis do we 
find the characteristic sacs in the sediment; further, 
single scolices with a double-hook arrangement or rem- 
nants of the same and single hooks. (PL VIII., A, 4.) 

Pyelitis with Bilharzia hseniatobia is a manifestation 
of existing cystitis. We find the pyelitis in such cases 
complicated with profuse parenchymatous haemorrhage. 
In the sediment, besides numerous blood- and pus- 
corpuscles, and kidney- and bladder-epithelium, we find 
also fibrine flakes which contain the characteristic eggs 



268 ANALYSIS OF THE URINE. 

of Bilharzia heniatobia in great quantity. (See Hema- 
turia, p. 278). The urine is rich in albumen and dis- 
solved blood-coloring matters. 

The para- or perinephritis can not be recognized 
from the analysis of the urine, since the latter may 
appear normal in very high grades of the diseases. 

2. Hmmatwria. 

Hematuria in its strictest sense does not belong 
her&, since it is but a symptom and no idiopathic disease 
of the urinary apparatus ; but we believe that it should 
be here included, since it very often complicates the 
various diseases of the kidney, the kidney -pelvis, and 
the bladder, often proceeding from simple hyperemia, 
so that one is not always in a position to recognize the 
primary disease. On the contrary, one has very fre- 
quently to content himself with the very general di- 
agnosis, " Hematuria from unknown causes." 

The hemorrhages of the urinary apparatus may be 
divided according to their character into three classes : 

a. Hemoglobinuria (Vogel's hematinuria) ; 

b. Parenchymatous hemorrhage ; 

c. Profuse hemorrhage from rupture of the larger 
vessels. 

I. Ilcemoglohinuria betrays itself by a reddish-brown, 
brownish-black, or at times lake-colored urine, which 
even after standing for hours deposits no red sediment 
of blood-corpuscles. It retains its homogeneous red- 
brown color, because the blood-coloring matters are in 



DISEASES OF THE URINARY APPARATUS. 269 

solution. The reaction is generally acid and the specific 
gravity lowered. The urine contains a great mass of 
hseinoglobine and methaeinoglobine, In the sediment 
we find at times epithelial (hemorrhagic) and molecular 
detritus, colored brown by the coloring matters of the 
blood. 

II. Parenchymatous hemorrhage exhibits a red- 
brown, often coffee-colored urine, which after long stand- 
ing retains its homogeneous red-brown color, but which, 
however, deposits a sediment, though often very slight, 
colored red-brown by blood- corpuscles. It generally 
reacts acid, has a varying specific gravity, and contains 
in solution more or less altered hsernoglobine. 

The sediment is characteristic of parenchymatous 
haemorrhage. We find in it blood-corpuscles of various 
sizes. Often normal disk-formed corpuscles are seen, 
with a rather indistinct depression ; they also appear 
roundish, spherical, and colored somewhat brown. Fre- 
quently they are quite colorless, without fluid contents, 
similar to small rings. 

In the field we often observe, besides the greater 
spheres, corpuscles only half or a quarter the usual size, 
and still smaller, down to fine dust-particles. 

These microcytes, which in the last few years have 
been seen so often in the blood of patients, are charac- 
teristic of parenchymatous haemorrhages of the urinary 
apparatus, and have been recognized as such for a long 
time. 

III. Profuse hemorrhage from the large vessels. — In 
this case we find the urine colored dark reddish-yellow, 



270 ANALYSIS OF THE URINE. 

or red, similar to venous blood. The reaction is usually 
neutral or alkaline, and the specific gravity is varying. 
The urine contains generally only traces of blood-color- 
ing matters in solution ; only when the urine is strongly 
alkaline from carbonate of ammonia — and this is but 
seldom — considerable blood-coloring matters are found 
in solution. 

Usually such urine deposits its entire blood as a 
considerable bright-red sediment after a few hours, and 
then appears of a normal yellow color. 

Albumen arising from blood-serum is always present 
in the urine. The sediment consists throughout of nor- 
mal disk-form corpuscles, in size similar to those of nor- 
mal blood. Sometimes there appear also in the sedi- 
ment blood-clots of various shapes. 

These three forms of haemorrhage can occur as well 
from the bladder as from the kidney -pelvis and the kid- 
ney, and consequently one is not always fortunate enough 
to know exactly from what part of the urinary appara- 
tus the haemorrhage originates. 

1. The reaction should be first considered for the 
differential diagnosis. We find usually that the urine 
accompanying haemorrhage of the kidney is acid, and 
with haemorrhage of the bladder it is alkaline. This, 
however, is not always the case ; for these conditions 
only hold when the haemorrhage is complicated with a 
purulent catarrh, either of the kidney-pelvis or of the 
bladder. Here, also, the reaction with litmus is not 
always to be relied upon ; for, with a profuse haemor- 



DISEASES OF THE URINARY APPARATUS. 271 

rhage through bursting of one of the greater vessels, the 
alkalinity of the blood may overcome the acidity of the 
urine, and we may find, in spite of the fact that the hae- 
morrhage does not come from the bladder, an alkaline 
reaction. In like manner the urine might become alka- 
line from the internal use of alkalies or alkaline mineral 
waters. Or perhaps the pyorrhoea of the kidney-pelvis 
might be so profuse that the alkali of the pus-serum 
could overcome the acidity of the urine. In such cases 
we would have an alkaline reaction of the urine from 
haemorrhages which had not their origin in the bladder. 

On the other hand, it must not be denied that 
haemorrhages do occur in the bladder where the urine 
shows an acid reaction. This appears constant when 
there is no purulent catarrh of the bladder, and when 
the haemorrhage is not profuse. 

The reaction of the urine with litmus alone is not 
sufficient for locating the haemorrhage. 

More important for this determination is the proof 
of a large amount of ammonium carbonate ; for when 
this is present in quantity, the probability is great that 
the haemorrhage is from the bladder, especially if at the 
same time crystals of ammonio-magnesium phosphates 
appear in the sediment. (PL IV., B.) 

2. The color of the urine should have even more 
weight than the reaction with litmus. The older prac- 
titioners connected the red-brown and brown-black 
shades of the urine with kidney-haemorrhages, and the 
bright-red color with haemorrhages from the bladder ; 
this, however, is not always the case. The brown, red- 



•272 ANALYSIS OF THE URINE. 

brown, and brown-black tones of the urine arise from 
decomposed haenioglobine (niethaeinoglobme), and can 
only occur in those cases where the blood has been inti- 
mately mixed with the urine for a long time, at the tem- 
perature of the body — i. e., within the urinary apparatus. 
We find usually such a condition with parenchymatous 
haemorrhage ; the blood mixes gradually drop by drop 
with the urine, the corpuscles remaining for a long time 
with a relatively great amount of fluid matters, the 
products of retrograde tissue-metamorphosis. By this 
intimate mixing the urinary constituents have time to 
exert their destructive influence on the blood-corpuscles, 
and finally to change the red haemoglobine to the brown 
methaemoglobine. 

For this reason parenchymatous haemorrhages from 
the bladder (carcinoma of the bladder) also give to the 
urine the red-brown and brown-black color. 

It is quite otherwise, however, with profuse haemor- 
rhage, caused by the rupture of large vessels (bladder- 
haemorrhoids). In such cases, at one time a great quan- 
tity of blood enters the urinary apparatus, especially the 
bladder, and quickly distends it. The unusual disten- 
tion is followed by immediate contractions of the blad- 
der, micturition ensues, and blood is passed before the 
urine has had time to decompose the haemoglobine. 

Since bladder-haemorrhages arise mostly through 
rupture of the vessels, and kidney-haemorrhages, on the 
other hand, are mostly parenchymatous, the brown-red 
color of the latter and the bright blood-red color of the 
former are of value for the diagnosis. 



DISEASES OF THE URINARY APPARATUS. 273 

3. The specific gravity of the urine has a diagnostic 
value, inasmuch as we find generally, from haemorrhage 
of the kidney and kidney-pelvis, such a condition of the 
organs that polyuria ensues (pyelitis), in consequence of- 
which the specific gravity is lowered, while with bleed- 
ing from the excretory passages there seldom arise dis- 
eases (cystitis) which cause polyuria ; hence in the latter 
case the specific gravity is normal. 

4. Blood-coagula. — The form of the clots when pres- 
ent in the urine sometimes shows with certainty the 
location of the hemorrhage. 

If the coagula are soft and have the color and con- 
sistence of freshly clotted blood, then they have not 
existed for a long time. If, however, they are without 
color or appear somewhat dirty yellow, they are of older 
date and have been retained in the urinary apparatus a 
longer time. Likewise short rod-shaped clots arise at 
times from the distended kidney-pelvis (Simon), and 
appear in the urine after haemorrhage from the kidneys. 
These were formerly considered as concretions, and 
thought to consist of pure fibrin. (Heller.) 

The coagula which occur long and rod-shaped indi- 
cate a haemorrhage from the kidney, while the lumpy, 
torn, irregular masses should come from the bladder. 
Further than this, it must be emphasized that only the 
long and rod-shaped blood-clots afford a certain indica- 
tion of the place of origin of the haemorrhage. If such 
forms occur, the seat of the difficulty must be above the 
ureters, for the rod-shapes are caused by passage of the 
clots through the same. We have seen a case, where a 

18 



274 ANALYSIS OF THE URINE. 

man forty-nine years old, suffering from a palpable neo- 
plasm of the right kidney (with hematuria), repeatedly 
passed blood-clots 10 to 15 centimetres long, as thick as 
a lead pencil. The irregular lumps are not very charac- 
teristic, for they may occur from the kidney-pelvis as 
well as from the bladder. Blood may also pass in a 
fluid state from the kidney to the bladder, and then 
coagulate. 

Coagula are not constant in connection with haema- 
turia. Parenchymatous and profuse haemorrhages only 
seldom give rise to clots ; consequently they occur most 
frequently when the bleeding arises from vessels of small 
calibre. 

5. The microscopic analysis furnishes the greatest 
aid to the differential diagnosis of haematuria. 

The so-called blood-cylinders (PL V., A) and the 
haemorrhagically tinged kidney-epithelium are character- 
istic of parenchymatous kidney -haemorrhage. In severe 
kidney-haemorrhages, however (if they are from vessels 
of large calibre), we do not find them. It is very prob- 
able that kidney-epithelium, at least in single cells, is 
present in the sediment ; but the great mass of blood 
present conceals these cell-forms, so that one sees 
nothing but blood-corpuscles under the microscope. 

Bladder-haemorrhages are often not characterized by 
any microscopic indications. At times we find in the 
sediment an increased amount of bladder-epithelium and 
crystals of ammonio-magnesium phosphate. 

Having described the micro-chemical characteristics 



DISEASES OF THE URINARY APPARATUS. 275 

of hematuria (hemorrhages of the urinary apparatus) 
in general, we will now mention those diseases which 
afford opportunities of observing them, and in every 
case where it is possible endeavor to furnish new 
grounds for diagnosis. 

I. Hemoglobinuria (with or without methsemoglo- 
binuria) occurs with haemophilia, scurvy, malignant 
intermittent fever, putrid typhus fevers, and especially 
with those diseases which are accompanied by a so- 
called dissolution of blood; also after inhalation of 
hydrogen arsenide, carbonic acid, and similar gases. It 
is also observed after the transfusion of animal blood. 
[Exposure to cold seems also to be the cause of haamo- 
globinuria, especially in the so-called "paroxysmal" 
form.] 

II. Parenchymatous hemorrhage may, as already 
stated, come from the kidney (and its pelvis) or the 
bladder, or from the entire urinary apparatus. 

a. Haemorrhage from the kidneys, besides the above- 
mentioned cases, is found usually with hemoglobinuria 
in the following : 

1. Sometimes with acute febrile processes, especially 
with exanthemata, where the haemorrhage represents at 
the same time a high degree of hyperaemia. 

2. In the majority of cases of acute and chronic 
parenchymatous nephritis. 

3. Kegularly with atheromatous degeneration of the 
kidney-vessels. 

4. With thrombosis of the renal veins, as in general 
cachectic conditions, puerperal fever, not seldom with 



•276 ANALYSIS OF THE URINE. 

uterine and crural phlebitis (Cruveilhier, "Anatomie," 
Livre 36) ; further, in consequence of severe injuries of 
the kidney, at times along with traumatic nephritis ; 
also from thrombosis produced by compression of tu- 
mors in the vicinity of the hilus. 

With nurslings who suffer from enteritis there at 
times occurs a thrombosis of the renal veins. Accord- 
ing to O. Pollak, one observes that after the termination 
of a diarrhoea children become icteric, a considerable 
diminution of the urinary excretion takes place, and in 
the sediment are found blood-cylinders, blood-corpuscles, 
and hemorrhagic epithelium. 

Further, kidney haemorrhages are observed — 

5. Constantly with renal calculi, although no severe 
pyelitis may be present. We find then in the sediment, 
besides blood-corpuscles of various sizes and kidney- 
epithelium, jagged crystals of uric acid or calcium 
oxalate. 

6. With cancer of the kidney, besides the parenchy- 
matous haemorrhage, we find nothing striking. Cancer- 
cells and cancerous tissue we have not found in the sed- 
iment of the urine ; still the possibility is not excluded 
that, if the cancer develops in the kidney-pelvis, we 
might find carcinomatous tissue in the sediment. In 
small children palpable tumors of the kidney as large 
as the fist are frequently observed, with no indications 
in the urine but a slight albuminuria. Haematuria is 
therefore not a constant but a very frequent symptom 
of new growths in the kidney. 

7. With renal phthisis or with cheesy inflammation 



DISEASES OF THE URINARY APPARATUS. 277 

of the kidney, the kidney-pelvis, and the ureters, we find 
in the sediment, besides microcytes, kidney-epithelium, 
pus-corpuscles, much molecular detritus, great quantities 
of vibriones and micrococci, and at times waxy cylinders, 
together with such as consist of vibriones and micrococci. 
h. Haemorrhage from the bladder is observed — 

1. With stone in the bladder and with catarrhal ul- 
cerations of its neck. The hematuria is of a lighter 
grade. 

In both cases, however, small blood- corpuscles (mi- 
crocytes) are not observed in the sediment. All are of 
normal size. If a complicating bladder-catarrh is present, 
the urine reacts alkaline, and in the sediment we find, 
besides blood- and pus-corpuscles, crystals of ammonio- 
magnesium phosphate and bladder-epithelium. 

Hematuria from bladder-stone becomes worse by 
exercise. The patient, therefore, should rest in bed. 
The hsematuria from catarrhal ulcerations, which occurs 
in the neck of the bladder usually after gonorrhoea, 
exhibits itself toward the close of micturition, when the 
sphincter vesicae begins to contract. 

2. With papilloma of the bladder and with carcinoma 
villosum arises also parenchymatous haemorrhage from 
the papillary growth of the mucous membrane. In the 
sediment we find not infrequently beautifully recogniz- 
able necrotic cancer-tissue, which confirms the diagnosis. 
However, one single microscopic investigation of the 
sediment does not suffice, since the cancer-tissue is not 
voided at each micturition. (For further particulars see 
section on villous cancer of the bladder.) 



278 ANALYSIS OF THE URWE. 

c. Parenchymatous haemorrhage from the entire uri- 
nary apparatus occurs — 

1. Sometimes after tlie evacuation from a paretic or 
paralyzed bladder and after catheterization. If for sev- 
eral years, on account of a paralyzed bladder, a portion 
of the urine had been accustomed to remain in it after 
micturition, and suddenly the entire amount is drawn 
off by a catheter, there arises necessarily a hyperemia 
ex vacuo, which becomes the more intense accordingly as 
the muscles of the bladder have become hypertrophied, 
rendering complete contraction impossible. Since also 
the secretory pressure in the kidney, which before was 
obliged to overcome the weight of the residual urine in 
the bladder, meets with no such resistance after cathe- 
terization, a parenchymatous haemorrhage ensues. 

2. Parenchymatous haemorrhage from the entire ap- 
paratus, but especially from the bladder, is observed in 
Egypt as a consequence of Bilharzia haematobia. There 
arises embolism of the vessels of the mucous membrane 
caused by the eggs of the Distoma haematobium. In 
such cases we find in the sediment, as already mentioned, 
little blood-coagula which the microscope shows to be 
imbedded with the long oval eggs of these parasites. 

III. Severe haemorrhages of the large vessels occur only 
from new growths and a varicose condition of the neck 
of the bladder. 

With new growths (villous cancer of the bladder) 
they only occur profusely when the cancer has existed 
for a long time and becomes ulcerated. With the so- 
called bladder-haemorrhoids the bleeding takes place so 



DISEASES OF THE URINARY APPARATUS. 279 

suddenly and profusely that the patient after one or 
two days becomes quite anaemic. It takes usually only 
a few days to destroy a perfectly healthy condition. 
Such haemorrhages may occur after several months or 
several years. In the sediment we find nothing but 
blood-corpuscles of normal size and character. 

In diphtheritic and croupous processes in the blad- 
der, such as occur in consequence of so-called blood-dis- 
solution, we find also blood in the ichorous, putrid, and 
alkaline-reacting urine. 

3. Gysto-Pyelitis and Py eh- Cystitis. 

By these terms we understand a purulent catarrh 
which at the same time has involved the pelvis of the 
kidney, the ureter, and the bladder. If the pelvis of 
the kidney is principally the seat of the disease, it is 
designated as cysto-pyelitis ; if however the bladder is 
most involved, then the disease is called pyelo-cystitis. 
Whether pyelitis or cystitis predominates is determined 
by the prevailing characteristics of the disease. 

If pyelitis prevails, polyuria is generally present, the 
urine has a neutral or slightly alkaline reaction, the 
specific gravity will be lowered, and the purulent sedi- 
ment will not stick to the glass. Albumen is found in 
greater proportion than the contained pus warrants, and 
in the sediment we find (besides pus-corpuscles) kidney- 
and bladder-epithelium and isolated triple-phosphate 
crystals. The pus-corpuscles seem to be well preserved, 
and sometimes to be pressed together in cylindrical 
masses. 



280 ANALYSIS OF THE URINE. 

If, on the contrary, cystitis prevails, then polyuria is 
not present, and the urine reacts strongly alkaline and 
has a normal or slightly lowered specific gravity. The 
sediment is glutinous, and the alkaline pus sticks to the 
glass. Albumen is present in greater mass than corre- 
sponds to the contained pus. Carbonate of ammonium 
is present in considerable amount. 

In the sediment we find the pus-corpuscles much 
swollen and a great abundance of triple phosphates ; we 
also find isolated scales of kidney- and bladder-epithe- 
lium. 

Cysto-pyelitis and pyelo-cystitis occur very frequent- 
ly with stricture of the urethra, hypertrophy of the 
prostate, and with paresis or paralysis of the bladder. 

From cystitis or from pyelitis arises very often, 
through contiguity, cysto-pyelitis or pyelo-cystitis. It 
even happens that cystitis alternates with pyelo-cystitis 
and pyelitis with cysto-pyelitis. 

Cysto-pyelitis as well as pyelo-cystitis can be caused 
by all those noxious circumstances which bring about 
cystitis and pyelitis. (See sections on Cystitis and Pye- 
litis.) 

The prognosis depends upon the ^etiological indica- 
tions and the severity of the prevailing disease. 

C. Forms of False Albuminuria. 

The false albuminuria differs from the true and 
from the mixed form, in that the albumen is always 
present in quantities corresponding to the contained 



DISEASES OF TEE URINARY APPARATUS. 281 

pus or blood. The albumen found is that of the pus or 
blood-serum. If both suddenly disappear from the 
urine — for instance, a few days after the opening of an 
abscess in the bladder, or as happens after the bursting 
of a varix in the neck of the bladder — then the albumen 
also disappears from the urine. 

From the foregoing we see that true albuminuria is 
only brought about by changes in the kidney, while the 
origin of the false is always in the excretory passages 
and bladder. During the diseases of the pelvis of the 
kidney, on account of the immediate contact with the 
kidney proper, a form of mixed albuminuria occurs, 
which we have previously alluded to. There remains 
much to be said concerning the diseases of the bladder 
and urethra, for these give rise to different forms of false 
albuminuria. 

1 . Cystitis — Uladder- Catarrh. 

We distinguish a chronic and an acute bladder- 
catarrh, and with each of these three grades. 

In bladder-catarrh of the first grade, the urine con- 
tains neither albumen nor pus, but simply a great 
increase of mucus, and possesses a slight acid reaction. 
In the second grade the urine reacts alkaline, contains 
albumen and pus, and has a glutinous greenish sedi- 
ment. In the third grade we have a putrid viscous 
urine with a strongly alkaline reaction, containing much 
albumen, pus, and blood. This is followed by ulcera- 
tive processes in the bladder, often complicated with 
suppurative nephritis. 



282 ANALYSIS OF THE URINE. 

The urine from bladder-catarrh shows generally an 
alkaline reaction, and many practicing physicians diag- 
nose this by the litmus test. 

While this is generally true, there are also cases 
when with cystitis the urine gives an acid reaction. 
This is for the most part noticeable in freshly passed 
urine, which, however, becomes alkaline in a few hours. 

a. Acute Bladder- Catarrh, first grade. 

Conditions. — The amount of urine is not increased ; 
it has a normal or dark wine-yellow color and is turbid. 
The specific gravity remains unchanged. The reaction 
is weakly acid, but in a few hours becomes alkaline. 
The sediment is considerable, but cloudy, not compact. 

The normal constituents are unchanged. 

Of the abnormal constituents, we find carbonate of 
ammonium in small amount ; albumen is not pres- 
ent. 

The sediment consists chiefly of an increased cloudy 
mucous secretion. Microscopically we find mucus-cor- 
puscles (young cells) and a small amount of bladder- 
epithelium. After a few hours we find also single crys- 
tals of ammonio-magnesium phosphate. 

The acute bladder-catarrh of the first grade represents 
generally a partial disease of the mucous membrane, 
such as occurs with prostatitis after gonorrhoea, or after 
instrumental investigation of the bladder and urethra. 
In women with malpositions of the uterus such a blad* 
der-catarrh usually accompanies menstruation. 



DISEASES OF TEE URINARY APPARATUS. 283 

b. Chronic Bladder- Catarrh, first grade. 

This form is characterized by a wine-yellow, very tur- 
bid urine, with a normal specific gravity, and whose 
twenty-four hours' amount is not increased. The reac- 
tion when first passed is acid, but in a few hours changes 
suddenly to alkaline. The sediment is considerable and 
cloudy. Sometimes the urine, when freshly passed, with 
an acid reaction has a peculiarly strong urine odor. The 
turbidity does not settle, and consists in great part of 
bacteria. 

The excretion of normal constituents is not al- 
tered. 

Of the abnormal constituents, carbonate of ammo- 
nium is present in small quantity ; albumen is not pres- 
ent. 

The sediment consists mainly of an increased cloudy 
mucous secretion, with bacteria. Microscopically we 
find single mucus-corpuscles, and also bladder-epithe- 
lium. After a few hours we find single triple-phosphate 
crystals in the sediment. 

Such urine is constant with persons who find them- 
selves obliged to employ catheters for the passage of 
urine, as with hypertrophy of the prostate, paresis of 
the bladder, and similar hindrances to urination. This 
first stage of bladder-catarrh occurs without exception 
in old women who have borne many children, or have 
been subjected to circumstances which lead to diseases 
of the uterus. 



284 ANALYSIS OF THE URINR 

c. Acute Bladder-Catarrh, second grade. 

This differs from the first grade chiefly by the pus 
contained in the nrine. 

The urine has a dark wine-yellow color, and is tur- 
bid. The turbidity consists of mucus and pus, while in 
the first grade we only find mucus. The specific gravity 
is normal. The twenty-four hours' amount is not in- 
creased. The reaction of the freshly passed urine is 
alkaline. The sediment is greenish-yellow, and sticks 
fast to the glass. 

The excretion of the normal constituent is only so 
much altered that a part of the urea has changed to car- 
bonate of ammonium. 

Of the abnormal constituents, albumen is present 
in amount corresponding to the pus contained in the 
sediment ; ammonium carbonate is present in consider- 
able quantity. 

The sediment consists principally of an alkaline pus 
mixed with crystalline and amorphous earthy phosphate. 
Microscopically we find single blood-corpuscles, urate of 
ammonia, and much bladder-epithelium. 

Such urine is found with hypertrophy of the pros- 
tate, after using the lithotrite on large and hard stones, 
after dilatation of strictures, after catheterization and 
other instrumental investigations ; further, through con- 
tinuity, with gonorrhoea and acute prostatitis ; and final- 
ly, after catching cold, especially from exposure to cold 
and moisture. In women, an acute bladder-catarrh with 
ometimes observed after operation on the uterus 



DISEASES OF THE URINARY APPARATUS. 285 

and vagina, with perimetritis and pericystitis, and after 
exhibition of cantharides, copaiva, and similar powerful 
drugs. Badly fermented new beer should also be enu- 
merated as a cause. 



d. Chronic Bladder- Catarrh, second grade. 

Characteristics. — A turbid wine-yellow urine, the tur- 
bidity being caused by pus-corpuscles and bacteria, while 
in the chronic bladder-catarrh of the first grade it is oc- 
casioned by mucus and bacteria. The twenty-four hours' 
amount is not increased. The specific gravity is normal. 
The reaction even when passed is alkaline. The sedi- 
ment is greenish-yellow and sticks to the glass. 

The excretion of the normal constituents, as also in 
the acute catarrh, is only so much altered that a greater 
part of the urea has changed to carbonate of ammonium. 

Of the abnormal constituents, we find albumen in 
the urine in amount corresponding to the pus in the 
sediment, and much carbonate of ammonium. 

The sediment consists chiefly of alkaline pus mixed 
with crystalline and amorphous earthy phosphates. 
The pus-corpuscles are found greatly distended, their 
contour destroyed, and their nuclei coming out. Often 
we only find free nuclei, imbedded in a homogeneous, 
turbid, ground sediment, and besides these bacteria and 
single bladder-epithelium cells. 

Often the pus is completely dissolved in a urine rich 
in ammonium carbonate, whereby the urine becomes 
sirupy and has a stringy consistence. 



886 ANALYSIS OF THE UMNK 

Such mine is found with hypertrophy of the pros- 
tate, paresis of the bladder, and with serious strictures 
and similar impediments to the urinary excretion. 

e. Acute Bladder-Catarrh, third grade. 

This grade embraces those processes which are 
designated as parenchymatous cystitis and pericystitis. 

While we are unable always to diagnose these dis- 
eases by the investigation of the urine alone, it assists 
the diagnosis very materially, in that by the analysis we 
can not overlook a severe form of purulent bladder- 
catarrh. 

If the amount of pus is very disproportionate, then 
we may suspect the discharge of a bladder-abscess. 

The uroseopic indications are similar to those of 
acute bladder-catarrh of the second grade, with the 
exception that the purulent sediment does not stick to 
the glass and is mixed with blood in greater proportion. 
Albumen is present in larger amount than corresponds 
to the pus and blood contained in the urine. 

f. Chrome Pd adder-Catarrh, third grade. 

This is a purulent catarrh complicated with ulcer- 
ative pn in the bladder. 

The urine is of a dirty brown-yellow color, and has 

a cadaverous odor. The reaction is strongly alkaline. 

The turbidity proceeds from bacteria and blood- and 

The specific gravity i- lowered. The 

aent is dirty yellow, and sticks to the gla>s. 



DISEASES OF THE URINARY APPARATUS. 287 

The excretion of normal constituents is diminished. 

Of the abnormal constituents, we find much albu- 
men, blood-coloring matters, carbonate of ammonium, 
and sulphide of ammonium. 

The sediment consists of alkaline-reacting pus mixed 
with blood and earthy phosphates. Microscopically we 
observe in large quantities bacteria, molecular detritus, 
and single cells of bladder-epithelium. 

This process comes from paralysis of the bladder 
and high stages of prostatic hypertrophy. It is com- 
plicated by suppurative nephritis or pyelo-nephritis. 
The appearance of uraemia or ammonseniia then closes 
the scene. 

Similar urine comes with tuberculous ulcerations of 
the bladder and with diphtheritis. 

With croupous processes in the bladder, which some- 
times occur with women, very large plates of reddish- 
white membrane are excreted with the urine, which 
consist of fibrine. They are often from the size of a 
half dollar to that of the hand. 

Very often upon the passage of the urine cysto- 
spasmus is confounded with bladder-catarrh, because 
the symptoms of both diseases are very similar. The 
investigation of the urine alone can determine the dif- 
ferential diagnosis. 

With vesical spasms the urine is generally clear, and 
in case of turbidity this arises from earthy phosphates 
which come down on excretion. The urine is moreover 
pale, and reacts weakly acid or neutral. 

By the heating test the urine becomes turbid, for by 



288 ANALYSIS OF THE URINE. 

this means the earthy phosphates and carbonates fall, 
which are as;ain dissolved on addition of acetic acid. 
Sodium carbonate is also sometimes present. 

Albumen, pus, ammonium carbonate, etc., in contra- 
distinction to cystitis, are not present. 

In the sediment we find calcium carbonate, crystal- 
line calcium phosphate, and amorphous earthy phos- 
phates. Triple phospnates and bladder-epithelium are 
wanting. 

2. New Growths in the Bladder. 

Since the haemorrhages of the bladder and their 
aetiological conditions have been described in the sec- 
tion on hematuria, we will only allude to them in so far 
as they are in close connection with bladder forma- 
tions. 

The following growths are found in the bladder : 

(a.) Simple fibrous polypi, which project into the 
cavity of the bladder ; these are of rare occurrence. 

(b.) Medullary sarcoma ; also of rare occurrence. 

(c.) Epithelioma. 

(d.) Villous or vascular tumors. 

1. Fibrous polypi cause simply a bladder-catarrh of 
the second grade, and only when ulcerated do we find 
blood in greater or less amount in the sediment. 

No histological elements characteristic of this form 
of tumor are found in the sediment. We can not there- 
fore diagnose this formation from the analysis of the 
urine. 

2. Medullary sarcoma. — The same is true of medul- 



DISEASES OF THE URINARY APPARATUS. 289 

lary sarcoma, except that in later stages it causes a 
bladder-catarrh of the third grade. The urine is at times 
greenish-brown, with a strongly putrid odor. In the 
sediment we find much molecular detritus, but other- 
wise no characteristic elements which serve for the 
diagnosis. 

3. Epithelioma generally develops slowly, and some- 
times occasions a bladder-catarrh of the second and 
sometimes of the third grade. The sediment is always 
more or less blood-colored. 

The microscopic investigation develops oftenest (be- 
sides blood- and pus-corpuscles) numerous p'eculiar small 
epithelial cells, which now and then appear in such 
large quantity that their number seems to equal the pus- 
corpuscles. 

The epithelial cells are small, round or oval, not dis- 
similar to kidney-epithelium. Sometimes they may be 
caudate, showing two or three small projections. The 
nuclei are frequently very large and brightly glistening, 
and several are visible in the same cell. Sometimes ten 
or twelve of these cells hang together and form an epi- 
thelial shred. (PL VIII., B.) 

One is not justified in diagnosticating epithelioma 
from the appearance of the various cell-forms in the 
sediment. If, however, a suspicion exists as to its 
presence, it is greatly strengthened by the indications 
of the microscopic investigation. 

4. Villous or vascular tumors can always be recog- 
nized from the investigation of the urine. 

At times two kinds may be distinguished : 1st, the 

19 



290 ANALYSIS OF THE UBTNB. 

papillary growth (papilloma) of the mucous membrane ; 
and '2d, villous cancer proper. 

Parenchymatous haemorrhage? are common to both 
forms, which mar be accompanied by a bladder-catarrh 
of the second or third grade. In the first case only, 
after the sloughing off of the papillary growth which 
has become necrosed, healing may take place : while in 
true villous cancer a cachectic condition arises, which 
soon carries off the patient. 

The villous cancer consists of a more or less soft 
mass, which, being of the consistence of medullary tis- 
sue, appears to involve the back and under wall of the 
bladder, so that the thickening or tumor may be felt by 
introducing the ringer into the rectum. Upon this 
tumor, forming at the same time its covering, the true 
cancerous tissue develops itself. This consists of dilated 
capillary vessels and a thinner or thicker layer of epi- 
thelium. 

Papilloma of the bladder, on the contrary, is confined 
simply to the mucous membrane. T\ e are unable to 
find a thickening of the bladder-wall or a tumor from 
rectal investigation 

From the fact that such a difference exists between 
the-e two forms of bladder-growth, the question arises 
whether we may not be able to diagnose them with cer- 
taintv from urinary investigation alone. This, however, 
is n<>t possible, because not infrequently papilloma of 
the bladder after a time \ er into villous cancer. 

Although there are some characteristic indication- for 
the microscopic recognition °' villous tissue, they are 



DISEASES OF THE URINARY APPARATUS. 291 

not sufficient to insure a correct differential diagno- 
sis. 

If we find beautifully constructed villous tissue in 
fine branches, with a very thin epithelial covering, we 
generally suppose that we have to deal with a papillary 
growth in the bladder. If, on the contrary, we find 
villous tissue with a thick epithelial covering, so that 
one can not distinguish the broadened vessels of the 
villus, we conclude usually that we have a villous can- 
cer to treat. 

These indications from the urine are, however, less 
weighty than the local proof of a swelling in the blad- 
der-wall and the accompanying cachectic condition. 

On account of the difficulty in separating these two 
forms of villous tumor of the bladder, it seems proper 
to treat them here as possessing characteristics common 
to both. 

The urine shows the following characteristic indica- 
tions with villous tumors : 

The twenty-four hours' amount is not increased. 
The specific gravity is normal. The color of the urine, 
as with parenchymatous haemorrhage, is red-brown to 
brown-black. The turbidity is due to blood- and pus- 
corpuscles. The reaction is generally, though weakly, 
acid. Only when the villous tumor begins to increase 
rapidly, and the accompanying bladder-catarrh causes 
a greater excretion of pus, does the urine possess an 
alkaline reaction. The sediment is fine and flocculent, 
brownish to brown-red in color, and contains reddish 
or flesh-colored little fibres or larger similar shreds. 



292 ANALYSIS OF THE URINE. 

The consistence of the urine is usually that of a thin 
fluid, though there occurs sometimes with villous tumors 
(but only temporarily) a fibrinuria with its peculiar 
gelatinous appearance. This is the only disease of the 
urinary organs in our latitudes in which even a transi- 
tory fibrinuria has been observed. 

The mrine when freshly passed appears as a thin 
fluid ; but in a few minutes it suddenly stiffens to a 
jelly-like mass, which can scarcely be poured from the 
vessel. After long shaking the urine again becomes 
fluid, and may be used for further investigation. The 
color of the urine with fibrinuria is not always in- 
tensely bloody, but sometimes only slightly reddish 
yellow. 

Fibrinuria (with villous tumor) is always accom- 
panied by severe strangury. One can easily understand 
that with strong spasmodic muscular contractions of the 
bladder a compression of the blood-vessels penetrating 
the muscular layer follows. Since the veins, because of 
the thinness of their walls, are more compressible than 
the arteries, there must arise a stasis in the vessels of 
the villous tumor. If the tension is very great in the 
vessels, a rupture of them may occur, and haemorrhage 
into the bladder ensue. If, on the other hand, the ten- 
sion is not sufficient to rupture the vessel-walls, then the 
plasma exudes from the capillaries, and coagulates after 
the excretion of the urine because of the contained 
fi brine.* 



* Such a fibrinuria caused by severe strangury has been observed by U8 
in three cases. 



DISEASES OF TEE URINARY APPARATUS. 293 

The excretion of normal matters with villous tumors 
is not altered. 

Of the abnormal constituents, albumen and blood- 
coloring matters are found in considerable quantity. It 
is especially to be remarked, that with villous tumors 
there is always more albumen in the urine than corre- 
sponds to the amount of pus or blood in the sediment. 
This condition depends upon the increased tension with- 
in the supplying vessels of the villous tissue. 

Since these appearances, accompanied at the same 
time by an acid reaction of the urine, are very similar to 
the indications of true albuminuria, one must be ex- 
tremely careful in such cases not to diagnose a kidney- 
affection without having distinctly recognized kidney- 
cylinders in the sediment. This precaution is the more 
necessary, as the inexperienced may easily confuse single 
delicate villous shreds with kidney-cylinders. 

Ammonium carbonate is not always provable. 

The flocculent sediment is usually brownish, with 
severe bladder-catarrh dirty yellow, and with profuse 
haemorrhage after rupture of a blood-red color. The 
more blood or pus the urine contains, the more difficult 
it is to recognize the characteristic tissue-fibres which at 
times are very sparingly present. With profuse haemor- 
rhage especially it is only an accident if in the great 
amount of blood one finds a characteristic lump. With 
a purulent sediment' one must also be very careful, al- 
though the red lumps or flakes are much easier to be 
found in the greenish pus than in the dark blood. We 
therefore choose a comparatively clear and less bloody 



, ^ : : . IF THE UMTJTR 

urine for the search for villous tissue. After the sedi- 
ment has sufficiently settled, it should be emptied upon 
a watch-glass, and the red flakes removed on a needle or 
pincette and placed under the microscope* 

The chief constituent of the sediment is blood alone, 
or blood mixed with pus. The blood comes mostly in a 
fluid state, though frequently we observe clots of various 
sizes in the sediment. These are distinguished from 
villous tissue by the fact that they appear dark black- 
:r"L "lilr :_- \i--.~: :■..:- m^Cj dr? '_-::*_ ::-r-i 0~.r^. 
however, we find villous tissue inclosed in the clots 
of blood. The blood-corpuscles show the same forms 
as in parenchymatous haemorrhage; we find them of 
various sixes and spherical shape (microcytes ). 

Villous tissue appears in various forms, according as 
the urine possesses an acid or alkaline reaction, It is an 
error to suppose that the villous tissue appears as beau- 
ridil m:: 'ii'.zi-jLL-ri ;^ i> :-ir:^v :7:::r-::r: Ll ~.l- 
text-books. An unchanged representation of the living 
villous tissue never occurs in the sediment. Such can, 
however, be observed when accidentally a small frag- 
ment of the fresh growth has been detached and 
brought out in the orifice of the catheter. Usually 
only necrotic villous tissue is perceived, and this under 
the microscope may appear in numerous forms. These 
become necrotic and are cast off by the bursting of 
sels in the villus. 

In the commencement of the disease we find the 
most perfect villous tissue. We observe then not in- 
frequently, under the microscope, a small shred-like 



DISEASES OF TEE URINARY APPARATUS. 295 

structure, from which the tissue extends similar to the 
fringe of a napkin. The thinner the epithelial covering, 
so much more distinctly are seen the villi. Since the 
necrotic villi and their vessels are for the most part rup- 
tured, we find but seldom unaltered blood-corpuscles in 
the lumen of the dilated tubes. Beautiful villous tissue 
is found especially with papillary hypertrophy of the 
mucous membrane of the bladder. (PL YIXL, B.) 

One is not always so fortunate in his investigations ; 
for, especially with the proper villous cancer, having a 
thick epithelial covering, it is very difficult to find dis- 
tinct villi. The epithelial covering of the necrotic villi 
is in a state of molecular disintegration, so that the 
divisions of the single cells are no longer apparent. It 
is infiltrated with blood- and pus-corpuscles and teeming 
with bacteria. Sometimes one sees in this molecular 
mass true branching forms which show the ground- 
structure and blood-vessels of the villous tissue. 

Although histologically in such cases we have no 
characteristic points for recognizing true villous tissue, 
yet there are other veiy important microscopic data 
which confirm the diagnosis of the same. They are as 
follows : 

Under a high power of the microscope, if one ex- 
amines the necrotic tissue, we find single spots of the 
epithelial covering colored brownish. On examining 
these spots more carefully, we observe, if the urine 
possesses an acid reaction, beautiful yellow or brown 
rhombic plates of hsematoidine, and yellow grassy forms 
which consist of the same coloring matter. If we per- 



KM THE URIXE. 

mit a drop of I ruining) to flow under the cover- 

glass, then we observe under the mi hat the 

brown-yell- 9] t, and even the entire i villous 

? s rely green, blue, and violet 

idine > of of old ha?mor- 

rhag: tissue, and is I xtent of diagno-;:: signifi- 

canee for bladder-can -:. 

In such nee: i . ulpous tissue not seldom peculiar 
stale are found, which, as we learn from better pre- 
miens, are peculiai to viDons tiss I are 

found in the urine only in connection with it. Th 
are small, rless, round rosettes, which are only 

soluble in nd that 

without evolution of gas. Diluted acetic a: a not 

alter" them. T~ agist most probably of oxalate 

calcium . actively upon addition of 

ftei strong heating. Th-— supposed caleium- 
oxalate crystals we : a bef re stated, only in 

the rill us tissi] only in acid 

urine. 

If the urin- is sti _ly alkaline, and -iderable 

purulent bladd< rh is present, we find the nee: 

tissue perfectly incrusted with earthy phosphates and 
ammonium urate. Th has a distir 'ion 

as if sand had passed the urethra, and generally 
aD examination for stone. 

On examining the si 'ft parte <~'f these inenist- 
rind them to be infe sted with bacteria, accompai 
by homogeneous structure- e of fine nee«lle-f«»rmed 

:i< »sphatf of lime), and large ens- 



DISEASES OF THE URINARY APPARATUS. 297 

tals of ammonio-magnesium phosphate and urate of am- 
monium. Sometimes in this incrusted flake we may 
find a portion of the hard groundwork of villous 
cancer. 

3. Bladder- Stone. 

If a stone is present in the bladder, we generally 
find blood in the urine after strong bodily exertion, 
which disappears after a long rest. With stone the day 
urine is consequently accompanied by more blood than 
the night urine. In this characteristic it differs from 
other forms of hematuria, in which the mixture of blood 
is constant at every evacuation. 

Bladder-stones frequently set up a bladder-catarrh. 
If the stones are small and have a smooth surface, i. e., 
stones consisting of uric acid, then we find only a blad- 
der-catarrh of the first grade c If, however, the stone is 
larger or has a rough surface (oxalate, phosphates), we 
then find a purulent bladder-catarrh of the second grade. 
The haemorrhage will be more severe, as the stone is 
rougher upon its surface. 

When there is present a smooth stone, the reaction 
of the urine is usually acid. If, however, a profuse 
purulent catarrh accompanies the stone, the reaction will 
be alkaline. 

It is important to consider whether a kidney-affection 
or pyelitis exists in complication with the bladder-stone, 
since it may be the case that, besides the stone in the 
bladder, we may also find concretions in the kidney- 
pelvis. We have then the indications of cysto-pyelitis 



298 ANALYSIS OF THE URINR 

with haemorrhage. (See the section on Mixed Albu- 
minuria.) 

The determination of the chemical constitution of 
the stones depends upon the chemical constituents of 

the mine ; for the crystalline and amorphous forms in 
the sediment constitute the outer layer of stone. The 
kernel in most cases consists of uric acid, since, in our 
experience, of 100 bladder-stones 90 per cent, contained 
the uric-acid kernel. 



4. Diseases of the Urethra and Prostate. 

These do not essentially change the character of the 
urine. With acute and chronic prostatitis, and also with 
hypertrophy of the prostate, occurs usually a bladder- 
catarrh of the first and second grades as a complication. 
To the acute and chronic prostatitis is added generally 
a bladder-catarrh of the first grade ; to hypertrophy of 
the prostate, corresponding to the retention of urine, 
sometimes a chronic bladder-catarrh of the first and 
sometimes of the second grade. With prostatic hyper- 
trophy of high degree, usually spermatozoa are found in 
the urine. It appears that the growing glandular tissue 
presses upon the muscular walls of the ductus ejacula- 
torii, and thereby allows the escape of the spermatic 
fluid. 

With spermatorrhoea the urine is generally neutral 
or alkaline. It becomes cloudy on heating, and the pre- 
cipitable earthy phosphates fall and dissolve upon addi- 
tion of acetic acid (Heller's bone-earths). Albumen 



DISEASES OF THE UBIJVABY APPARATUS. 299 

is not present. In the sediment we find, besides nu- 
merous spermatozoa, calcium-carbonate and calcium- 
phosphate crystals, and sometimes also ammonio-magne- 
sium phosphate. In the urine after the escape of semen 
we constantly find spermatozoa ; it is therefore very im- 
portant, before a diagnosis of spermatorrhoea is made, to 
ascertain whether passage of the urine brought for ex- 
amination has been immediately preceded by a pollu- 
tion or coition. 

With acute and chronic gonorrhoea we find in the 
sediment pus-corpuscles and single cylindrical epithelial 
cells from the urethra. Albumen, however, is not prov- 
able in the urine. 

Should it be doubtful whether the purulent sedi- 
ment of the urine arises from the urethra or a higher 
portion of the urinary tract, the patient should (accord- 
ing to Thompson) urinate into two vessels. The first 
half of the evacuation would contain the pus from the 
urethra, while the second portion would contain only 
the catarrhal secretion of the bladder or the kidney- 
pelvis. 

The so-called gonorrhoeal threads which almost con- 
stantly appear in the urine of gonorrhoea, even after 
normal healing, are usually catarrhal secretions from the 
ducts of the accessory glands of the urethra. Only the 
very long threads, which are seldom found, are formed 
in the urethra itself. 

Two kinds of gonorrhoeal threads may in general be 
distinguished. The first are thicker and longer, and 
have not infrequently a knob-like swelling on the end. 



300 ANALYSIS OF THE URINE. 

These arise usually from the pars prostatica urethra. 
The second are thin and short, and show no knob-like 
swelling. These arise generally from Littre's glands of 
the urethra. 

Such a thread under the microscope is seen to con- 
sist of pus-corpuscles, mixed with small cylindrical epi- 
thelial cells imbedded in a homogeneous ground-sub- 
stance. (PL VI, A, 2.) 

With croup of ' tJie urethra appear small and white, 
filmy or tube-formed structures, mixed with pus and 
blood. These consist of fibrine, and are washed out by 
the stream of urine. 



DR. ULTZMANN'S SACCHARIMETER 

FOE PKACTICINGr PHYSICIANS AND STUDENTS. 

The liigli price and complexity of the polarization 
apparatus generally used induced me to request of 
Herr Keichert a saccharimeter adapted for use with a 
microscope-stand, and in accordance with a design of 
my own. He cheerfully undertook the task, and has 
constructed a very useful instrument. The principle, 
importantly modified in its application, is that of the 
Mksherlich apparatus, which has been so variously ap- 
plied by physicians. 

The great advantages of this instrument over others 
are: 

1. No artificial source of light is needed, for the 
concave mirror of the microscope- stand brilliantly il 
luminates the field of vision. 

2. The apparatus itself is small (it is scarcely longe* 
than the fully elongated tube of a medium-sized micro 
scope) and needs no separate stand. 

3. By means of this instrument the percentage oi 
sugar can be directly calculated. 

4. The entire apparatus can be had for a compara 
tively very small cost. 



302 AXALTSIS OF THE URIXE. 

After three years' experience with it, during which 
time I have had the opportunity of analyzing many dia- 
betic urines, I can at present say that this instrument, 
in its latest form, answers all the requirements of the 
practicing physician, and I can therefore most highly 
recommend it. 

In using the apparatus, the tube, objectives, ocular, 
of the microscope are withdrawn, and in their 
place the saccharimeter is inserted and made fast to the 
stand by means of a small screw.* The concave mirror 
is then turned into position, and by look- 
ing through the instrument it is deter- 
mined whether or not it is properly ad- 
justed. 

In the accompanying figure a is the 
biconcave and b the objective lens of a 
small Dutch telescope, the focal distance 
of which extends to p ; c is the upper 
Nicol prism, with which a vernier is closely 
connected; d is a glass tube for holding 
the suspected fluid, which should be fil- 
tered or otherwise cleared up before an- 
alysis : p is a double plate of right and 
left rotating quartz; and f the lower 
Xicol pri-m. 

The arc [fixed scale] is so divided 
that one division of it represents one per 
cent, of grape sugar at a temperatur- 




M' 



* Th D Vienna are Reiehert's No. ITT. and Hartnach's 

I[[., bat the saccharimeter may be attached to any stand. 



DR. ULTZMAEN'S SACGEARIMETEE. 303 

20° C. By means of the vernier, tenths of a degree (i. 
e., of one per cent?) can be very approximative^ deter- 
mined. Since ten degrees of the vernier correspond ex- 
actly with nine degrees of the arc, to the percentage of 
sugar found must be added as many tenths as spaces 
are counted on the vernier up to that division which 
exactly coincides with a division of the arc. 

If, for example, the zero point of the vernier does 
not quite reach (toward the right) the five-point of the 
scale, it indicates that the percentage of sugar is more 
than four and less than five per cent. If it be desired 
to estimate the tenths per cent., and the sixth division 
of the vernier is the first (counted from the zero point) 
to coincide with a division of the arc, then six is the 
number of tenths required, and the apparatus would in- 
dicate in this case 4*6 per cent, grape sugar present. 

In estimating the strength of cane-sugar solutions, 
it is to be borne in mind that the polarization jDower 
of cane sugar is three quarters that of grape sugar. 

Both the above-mentioned kinds of su^ar turn the 
polarized ray to the right, albumen (i. e., serum-albu- 
men), on the contrary, toward the left, and as far to- 
ward the left as grape sugar toward the right. 

If the glass tube of the saccharimeter is empty, or 
contains a fluid holding in solution substances having 
no optical influence (for example, normal urine), the 
zero point of the vernier coincides exactly with the 
zero point of the scale, and the two halves of the field 
of vision are exactly isochromatic. 

If, on the contrary, an optically active substance is 



304 ANALYSIS OF THE URINE, 

contained in the fluid (as, for example, sugar), the nor- 
mal isochromatism of the two halves disappears, and a 
distinctly unequal coloring takes place. This is the 
more apparent the greater the amount of optically 
active substance present in solution. When this un- 
equal coloring occurs, the vernier is to be moved to- 
ward the right or left (according to the presence of 
sugar or albumen) until the color of the two halves is 
again exactly the same. The percentage is then read 
off the scale in the way above mentioned. 

If a diabetic urine is very light colored and clear, it 
can at once be put into the glass tube of the instru- 
ment and the determination made. If, however, it is 
dark and cloudy, and contains albumen, it is advanta- 
geous to first clarify it and remove all disturbing sub- 
stances. This is best accomplished by means of a ten 
per cent, aqueous solution of sugar of lead. The lead 
acetate causes in urine a copious white precipitate, con- 
sisting of lead chloride, phosphate, and sulphate, and 
the precipitate carries down with it all the coloring 
matter of the urine and such albumen as may be pres- 
ent. If the urine is then passed through a dry filter, 
the resulting filtrate is almost as clear as water, and is 
particularly well adapted for the apparatus. Since, 
however, the amount of sugar in the mixture (after the 
addition of the lead-acetate solution) differs from that 
in the urine, the amount of dilution must be taken into 
account in estimating the sugar present. It is best, 
therefore, to take 75 c.c. of urine, and to that add 25 
c.c. of lead-acetate solution, shake, and filter. In esti- 



DR. ULTZMANN'S SACGEARIMETER. 305 

mating the sugar present in the urine, one quarter of 
the percentage of the mixture added to that percentage 
will give the percentage of sugar in 100 c.c. of urine. 
In other words, the percentage of the mixture is three 
quarters that of the urine. 

For example, if to 75 c.c. of a dark, albuminous sac- 
charine urine have been added 25 c.c. of lead-acetate 
solution, the mixture filtered, and found to contain 4*8 
per cent, sugar, then 1*2 per cent, must be added to 
give the percentage in 100 c.c. of urine, which would, 
therefore, contain 4*8 -f- 1*2 per cent. = 6 per cent, 
sugar. 

In filling the glass tube, care must be exercised that 
no air bubbles are included in the fluid. It is well, 
therefore, to fill the tube as full as possible and push 
the glass cover on from one side before screwing on the 
top. 

[We have used the above-mentioned instrument for 
several months, and find it gives results agreeing within 
a small fraction of a per cent, with those given by Feh- 
ling's test with artificially prepared solutions of glucose 
in distilled water and urine, and with diabetic urine. 
In the latter case the sugar must be present in more 
than one per cent, to give satisfactory results. In 
using it one should look but a few seconds at a time 
and make several observations. — Teanslatoe.] 

20 



APPENDIX A. 

ALBUMEN. 

In view of the large amount of literature recently 
published concerning albuminuria, the addition of a 
few words, supplementary to the text, would seem de- 
sirable. 

With the increased delicacy of our tests, and the 
greater attention paid to the subject, albumen is now 
frequently detected where formerly it would have been 
overlooked. Thus, hundreds of cases have recently 
been reported, and by numerous observers, where albu- 
minuria has been found, and in at least a laree number 
of these cases the individuals were apparently healthy. 
For instance, Prof. Grainger Stewart found albuminu- 
ria in 31 per cent, of 407 persons in apparent health ; 
and Dr. G. R. Shepherd, in a collated total of 35,000 
examinations for life-insurance and other purposes, re- 
ported albumen found in 2 per cent. ; while Posner 

its, as the result of his investigations, that serum- 
albumen is constantly present (in small quantity) in 
normal urine. Unfortunately, the kind of albumen 
found has not always been stated, although it has usu- 
ally been serum-albumen or globulin. 



ALBUMEN. 307 

According to the chief characteristics of the differ- 
ent varieties of albuminuria observed, various titles 
have been proposed for them : thus we have " cyclic/ 1 
" paroxysmal/' " intermittent," a simple persistent," " di- 
etetic," and "physiological" {sic!). Dr. C. H. Kalfe 
advocates the use of the term " functional " to include 
these varieties, and defines as " functional albuminuria " 
that form " which is not dependent upon structural dis- 
ease of the kidneys, or proceeding from morbid condi- 
tions of the urinary passages." This term, although not 
new and not unobjectionable, would seem to be a con- 
venient one ; at least, until the physiology and pathol- 
ogy of albuminuria are better understood. 

We now know that albumen appears in the urine 
after severe muscular exercise, excessive mental work, 
cold bathing, and even ingestion of food (especially in 
the case of dyspeptics) or rising from bed ; and while 
in many of the cases reported there may have been 
hypersemia or structural disease (unrecognizable) of 
the kidney, yet in others it seems necessary for us to 
assign the condition to " faulty metabolism," or confess 
our ignorance as to its causation. 

What especially concerns the practitioner, however, 
is the fact that simply the occurrence of albuminuria 
does not warrant a grave prognosis or even rejection 
for life-insurance. Of more importance than its simple 
presence is the persistence of the albumen in the urine, 
its approximate amount (in functional albuminuria it is 
usually 0*1 per cent, or less), its accompaniments (es- 
pecially casts, cells, etc.), and its probable origin. 



308 ANALYSIS OF THE URINE. 

The two following tests — highly commended by 
some urine-analyzers — are appended: 

The Nitric- Mag nesian Test was suggested by Dr. 
Roberts, and consists of one volume strong nitric acid and 
five volumes saturated solution of magnesium sulphate. 
Owing to its specific gravity (1240), it is used by the 
contact method. It is claimed for this test that it is 
equal in delicacy to the mercuric iodide and phenic- 
acid tests, and acts as does nitric acid with albumen, 
mucin, and peptone. It is less corrosive than pure 
nitric acid, but can not be used with urine clarified by 
liquor potassse. 

The Phenic Acetic Acid Test was suggested by 
Millard, and is claimed by him to be as delicate as the 
foregoing. It behaves toward mucin, peptone, and the 
alkaloids as do the potassio-mercuric iodide and picric- 
acid tests. Its composition is ac. phenic (glacial), 95 
per cent., 3 ij ; ac. acet. pur., 3 vij. Mix, and add liquor 
potassse, §ij 3vj. 



APPENDIX B. 

SUGAR. 

The PhenylrHydrazin Test — The use of phenyl- 
hydrazin hydrochlorate as a test for sugar in the urine 
was first suggested by Dr. Eniil Fischer, of Erlangen, 
and has been advocated abroad, especially by Drs. von 
Jaksch, Ultzmann, and Grocco, and in this country 
first by Dr. A. K. Bond, of Baltimore.* It depends 
upon the formation of a crystalline substance, "phenyl- 
glucosazon," when to a solution of glucose the phenyl- 
hydrazin salt is added in the presence of an excess of 
sodium acetate. 

Ultzmann's method of using the test, slightly modi- 
fied by Bond, is the following: Into a test-tube fixe 
inches long pour the phenyl - hydrazin salt (a dry, 
crystalline, bran-like substance) to the height of about 
four tenths of an inch ; add powdered crystals of so- 
dium acetate to the same height above, and urine to 
one half the height of the tube (Ultzmann first removes 
albumen if it be present). This gives approximately 
by weight one part phenyl salt, two parts sodium ace- 

*" Medical ISTews," August 6, 1887, and "Baltimore Underwriter," 
September 20, 1887. 



310 ANALYSIS OF TEE UBIXE. 

. and fifteen parts urine. Shake the tube gently 
until the sodium acetate is dissolved, and then boil 
carefully for half a minute : set the tube aside, and ex- 
amine for crystals. If sugar is present, there will be 
deposited yellow, needle-like crystals, haying a strong 
tendency to form clusters or sheaves. These crystals 
melt at a temperature of 204° C, and are distinctly 
visible macroscopically if much sugar is present. The 
time required for the deposition of the crystals varies 
proportionally with the amount of sugar present. If 
there is a large quantity, fifteen minutes may suffice ; if 
a very small quantity, forty-eight hours may be re- 
quired. Whether the crystals are visible macroscopi- 
cally or not, the sediment should be examined with the 
microscope (a power of two hundred diameters am- 
plification is sufficient), when, amid the red globules 
caused by excess of the phenyl salt, will be seen beau- 
tiful needle-like crystals, in clusters, should the urine 
contain sugar. 

It is claimed for this test that it does not react with 
normal mine ; that it detects sugar in as small quantity 
a loea Fehling's test ; and that it reacts with all sub- 
stances of the sugar class which reduce alkaline copper 
solutions; thus it reacts with glucose, levulose, lact 
cane-sugar, maltose, and sorbin, but not with inosite or 
trehalose. Of these substances, however, levulose and 
lactose are the only ones occurring in urine which can 
1 with glucose, an 1 levulose rarely occurs 
without _ - . while lactose only occurs in the urine 
< >f pregnant or nursing women. This reagent does not 



SUGAR. 311 

spoil by keeping, and its mixture with urine being an- 
tiseptic, allows the crystals formed to be detected 
weeks after their precipitation. If all claims made for 
it be confirmed by continued trial, it will be perhaps 
our most satisfactory qualitative test for sugar. 

The folio wins; new tests for sugar have been advo- 
cated by H. Molisch : * Take 0*5 to 1 c.c. of urine and 
add to it 2 drops of a 15 to 20 per cent, alcoholic alpha- 
naphthol solution, and an excess of concentrated sulphu- 
ric acid ; shake, and, if sugar is present, a deep violet 
color is developed. On dilution with water, a violet- blue 
precipitate occurs, which is soluble in alcohol and ether, 
with a yellow, or in potassium hydrate with a golden- 
yellow color. If thymol be used instead of alpha- 
naphthol, a deep-red color is produced, and upon dilu- 
tion with water a carmine-red, flocculent precipitate, 
soluble with a pale-yellow color in alcohol, ether, and 
potassium hydrate, and with a bright yellow in ammo- 
nium hydrate. Most kinds of sugar, except inosite, and 
most glucosides, respond sooner or later to these tests. 
Indican does not. Urea, creatinin, xanthin, uric acid, 
allantoin, hippuric and succinic acids, phenol, and 
pyrocatechin give negative results. Molisch considers 
these the most delicate tests, however, and claims that 
they will detect 0*00001 per cent, of sugar. Normal 
urine responds to these tests when diluted with 300 
volumes of water. 

To distinguish normal from diabetic urine he recom- 
mends the following : (1) Dilute a specimen of normal 

* " Boston Medical and Surgical Journal," vol. cxvi, No. 15, p. 354. 



312 ANALYSIS OF THE URWE. 

and one of suspected urine with 100 volumes of water, 
and compare the colors resulting from the application 
of the the tests. (2) Dilute two similar specimens with 
400 volumes of water ; the diabetic urine will still re- 
spond to the test, while the normal will not. 

Seegen carefully examined these tests, and found 
that sugar in 0*05 per cent, gave both reactions distinctly. 
Solutions containing 0*01 per cent, gave with thymol a 
dark sherry-yellow color, and with alpha-naphthol a faint 
violet tint; but on dilution with water no precipitate 
was formed. Normal urine reacted, as described by 
Molisch, but on dilution with 100 volumes of water 
there was no precipitate. Various animal substances 
and secretions and chemically pure albuminous bodies, 
as peptone, egg-albumen, serum-albumen, and casein, 
also gave the same reactions. He therefore regards 
these tests as less delicate than Trommer's, and as of 
no value as tests for sugar alone. 

Molisch responds that these tests are more delicate 
than Fehling's solution, although with dilute solutions 
of sugar solid alpha-naphthol should be used instead of 
the solution. The albuminous bodies, he claims, give 
results somewhat resembling those with sugar, but the 
precipitates obtained upon dilution with water are of a 
different color (dirty-yellow or yellowish-brown), ex- 
cepting that with peptone, from those with sugar. Hy- 
drochloric acid also will dissolve these precipitates with 
a carmine-red or reddish-violet color, while the precipi- 
tate obtained with the sugar solutions is insoluble in 
this acid. In place of sulphuric acid, hydrochloric acid 



SUGAR. 313 

may be used in these tests, the mixture being subse- 
quently boiled for a minute. Fibrin, vitellin, serum- 
albumen, egg-albumen, and peptone do not give the re- 
action when hydrochloric acid is used. Normal urine 
gives the reaction when boiled with alpha-naphthol and 
hydrochloric acid, even if diluted ten times, and he 
therefore considers that it must contain sugar or some 
body as yet unknown. 

The experiments of Wedenski * and Udranzky f 
tend to prove the constant presence of glucose, or at 
least a carbohydrate, in the urine, and the latter states 
that the alpha-naphthol reaction of Molisch simply 
proves the presence of carbohydrates, but does not dif- 
ferentiate between them. 

* "Zeitschrift filr physiol. Chem.," xii. Bd., S. 122. 
t "Zeitschrift fur physiol. Chem.," xii. Bd., S. 377. 



APPENDIX C. 

MEW EEBU< TA N ES. 

Dk. Robert Ktbk * describes a new acid, which he 
found in the urine of three brothers, and which gave 
the reactions of Boedeker's alkapton. It reduced cop 
per but not bismuth salts, and readily oxidized in the 
presence of an alkali The urine containing it took on 
a dark color from the surface down on exposure to air. 
The acid ethereal extract of the urine deposited crystals 
of the acid in question, and they occurred in the form 
of long, thin prisms, with oblique ends, sometimes col- 
lected in stellate or sheaf-like clusters. The substance 
resembled glycuronic acid in some of its relations, and 
seemed closely related to pyrocatechin and protocate- 
chuic acid. He proposed to call it a urrhodinic acid." 
Its pathological significance is not known. 

An interesting case occurred in the practice of Dr. 
Frank Donaldson, Sr., of Baltimore, the urine of which 
was independently examined and reported upon by 
Drs. John Marshall f and T. Barton BruncJ The 
patient was apparently healthy, but had been re- 
peatedly rejected by life-insurance examiners, on ac- 

* • British Medical Journal," Xorember 17, 1886. 
Medical Sews," January 8, 1887. 
**on Medical and Surgical Journal," December 30, 1886, and Jann- 



NEW REDUCING SUBSTANCES. 315 

count of supposed glycosuria. His urine was perfectly 
clear and without sediment. On standing several hours 
it became first a reddish-yellow ; later, a brownish-red 
from the surface downward. It gave a port- wine red, 
later, an almost black color, with sodic hydrate. Xitric 
acid almost decolorized the fluid, but evolved no cara- 
mel odor. The substance produced a brown color in 
the supernatant fluid with Boettger's test, but did not 
reduce the bismuth salt. It gave a light violet color 
with thymol and sulphuric acid. It gave no appreci- 
able reaction with polarized light ; it did not ferment, 
and, according to Dr. Bond, did not react with phenyl- 
hydrazin hydrochlorate. It did, however, reduce cop- 
per salts, and gave the sugar reaction with Johnson's 
picric-acid test. With ferric chloride it gave a faint- 
green precipitate. Both Drs. Marshall and Brune iso- 
lated the substance in crystalline form, by methods de- 
scribed in their articles. Its crystals were opaque, 
needle-shaped prisms, arranged in groups radiating from 
a center. They melted at 140° C. Dr. Marshall found 
it to be an acid, and proposes the name of " glycosuric 
acid " for it. Possibly it is identical with Kirk's " ur- 
rhodinic acid"; apparently it is a phenol derivative. 

Leo,* after removing all the ordinaiy reducing sub- 
stances, such as uric acid, creatinin, coloring matters, 
etc., found, in three out of twenty-one cases of diabetes, 
a new substance belonging to the sugar series and iso- 
meric with glucose. It reduced strongly copper-oxide 

* " Deutsche raed. Wochen.," 1886, S. 869; and Virchow's " Archiv," 
Bd. 107, S. 99. 



316 AMALTSIB OF TEE URIXE. 

solutions; " - _ y: rate and non-fermentable. He 

did not find it in normal urine, and no name has been 

proposed for it. 

Leu rand in the mine of a patient having 

ateomalacia, cystitis, and nephritis, a new coloring mat- 
ter, which turned the urine a dark violet to brown 
color on exposure to air ( i. e.. oxidation ). and gave a 

"vn. later, yellow color with alkalies. It gave char- 
acteristic spectroscopic appearances. 

In addition to the substances above mentioned, the 
following, when introduced into the system, form com- 

inde or derivatives in the urine which have the 
power of reducing alkaline copper solutions, viz., tur- 
pentine (as mentioned in the text ). chloroform (un- 
changed), benzoic and salicylic acids (the sodium sali- 
cylate derivative also reacts with potassium picramate ), 
copaiba, hydroehinom phenol, benzol, tannic acid, gly- 
cerin, and ortho-nitrotoluol ( Laache ), cubebs and cam- 
phor (glycnronic acid being formed ). The glycuronate 
of potassium also forms crystals with phenyl-hydrazin 
hydroehlorate. but they melt at 114° to 115° C. 

B me of these substances are also active toward 
polarized light : thus, glycnronic acid is dextrogyrate, 
while the copaiba derivative is laevogyrate. The tur- 
pentine compound seems also to be fermentable. 

The occurrence in urine of such bodies as these, and 
others before mentioned, emphasizes the propriety of 
ning the patient as to his ingesta, and the necessity 
for using more than one test in examining for sugar. 

* u AmericaD Journal of the Medical Sciences," vol. xciv, p. 545. 



APPENDIX D. 

BLOOD. 

The Almen-Schonbein Test for blood in urine is 
highly commended by Laache* as very delicate and 
reliable. Its simplicity recommends it to physicians. 
To perform it, proceed as follows : Mix 1 c.c. of freshly 
prepared tincture of guaiacum with an equal volume of 
ozonized oil of turpentine (i. e., oil of turpentine which 
has been exposed to the atmosphere for a long time), 
and pour the mixture carefully down the side of a 
reagent glass upon the surface of the suspected urine ; 
the reagent will float upon the urine, and immediately 
between the two fluids will occur a resinous precipitate 
in the form of a grayish- white (later, dirty-yellow or 
green) layer, and directly above it, if blood is present, 
a beautiful indigo-blue ring, which will contrast sharply 
with the nearly colorless supernatant fluid. Upon 
shaking the contents of the glass, a clear blue emulsion 
will result. 

Mahomed's test, and Stevenson's modification of it, 
are based upon the same reaction, ozonic ether being 
used instead of oil of turpentine. Saliva, nasal mucus, 
and a salt of iodine occurring in the urine of those taking 
iodide of potassium, are said to cause a similar reaction 
(Tyson). 

* " Harn- Analyse," S. 91. 



ALPHABETICAL INDEX. 



A 

PAGE 

Abnormal Constituents 84 

Acetonemia 122 

Acetone 121 

Accidental Constituents 143 

Acid Albumen 94 

Acidity 46, 201, 270 

Albumen 91, 84, 215 

Nitric Acid Test for 88 

Nitric Magnesian Test for. . . . 308 

Boiling Test for 89 

Metaphosphoric Acid Test for 102 

Phenyl- Acetic Acid Test for. 308 
Potassium Ferrocyanide Test 

for 102 

Sodium Tungstate Test for .. . 102 
Potassio-Mercuric Iodide Test 

for 99 

Picric Acid Test for 100 

Albuminuria 242 

False 280 

Mixed 258 

Functional 85 

Alkali-Carbonates 144 

-Chlorides 73 

-Phosphates 80 

-Sulphates 82 

-Urates 151 

Alkapton 106 

Allantoin 55 

Ammonio-Magnesium Phosphate 164 

Ammonium Carbonate 140 

Urate 153 

Amyloid Kidney 255 



PAGE 

Anuria 234 

Apparatus 198 

Approximative Analysis 224 

B 

Bacteria 179 

Bilharzia 186, 267, 278 

Biliary Acids 136 

Pettenkofer's Test for 136 

Oliver's Test for 138 

Biliary Coloring Matters 131 

Gmelin's Test for 131 

Heller's Test for 132 

Ultzmann's Test for 133 

Marechalt's Test for 134 

Biliprasine 131 

Bilirubine 131 

Bladder 2V 

New Growths in 288 

Polypi in 288 

Medullary Sarcoma 288 

Villous Tumors in 289 

Epithelioma of 289 

Stone in 297 

Blood 273 

Corpuscles 171 

Coloring Matters 128 

Tests for 317 

C 

Calcium Carbonate 185 

Oxalate 155 

Phosphate 77 

Cancer Elements 184 

Villous 289 



320 



ALPHABETICAL INDEX. 



PAGE 

Casein 94 

Casts and Cylinders 173 

Fibrine 174 

Granular 175 

Hyaline 176 

Waxy 176 

Epithelial 177 

Uric Acid 178 

Bacterial 178 

Chemical Composition 48 

Chlorides 73 

Chlorine 219 

Chlorosis 238 

Chyluria 161 

Cloudiness 146 

Color 42, 271 

Coloring Matters 63, 127, 128 

Abnormal 125 

Concretions 189 

Analysis of 192 

Creatinine 71 

Determination of 212 

Cystine 156 

Cystitis 281 

Cysto-Pyelitis 279 

D 

Diabetes Mellitus 239 

Diacetic Acid 123 

Diagnosis 232 

Donne's Test 171 

E 

Earthy Phosphates 77, 161 

Echinococcus 186 

Entozoa 186 

Epithelium 167 

F 

Fat 159 

Febrile Urine 234 

Fermentation 146 

Fibrine '. 87 

Filaria Sanguinis 188 

Fungi 179 



G 

PAGE 

Galaoturia 160 

Globuline 94 

Glucose 104 

Glycosuria 119 

Gonorrhoea 299 

Gout 239 

H 

Haematinuria 130 

Haematoidine 295 

Haematoporphyrin 135 

Hematuria 275, 277, 278 

Hemine, Crystals of 129 

Hemoglobinuria 268, 275 

Heart, Diseases of 237 

Hemi-Albumose 96 

Hippuric Acid 71 

Hydrobilirubine 65 

Hydruria 233 

Hyperemia of Kidney 242 

I 

Icterus 236 

Indican 66 

Jaffe's Test for 69 

Stokvis's Test for 69 

Uroxan thine Test for 68 

Indigo 66 

Indol 69 

Inosite 119 

Intermittent Fever 240 

Todine, Determination of 145 

K 

Kidneys 19 

Histology of. 19 

Blood- Vessels of 24 

Nerves of 26 

Excretory Ducts of 26 

Haemorrhage from 275 

Hyperemia of. 242 

Cirrhosis of 252 

Atrophy of 252 



ALPHABETICAL INDEX. 



321 



PAGE 

Kidneys, Abscess of 254 

Amyloid 255 

Kyesteine 183 

L 

Lactic Acid 73 

Lactose 121 

Lactosnria 121 

Leevulose 120 

Leptothrix 180 

Leucaemia 240 

Leucine 124, 158 

Levulinic Acid 1 24 

Liver, Acute Atrophy of. 236 

Chronic Diseases of 240 

Lings, Diseases of 237 

M 

Magnesium Phosphates 163 

Melanine 131 

Meningitis 237 

Metallic Salts 144 

Methaemoglobine 128, 272 

Microcytes 174, 269 

Milk-Sugar 121 

Mucin 98 

Mucus 165 

Murexide Test 57 

N 

Nephritis 245 

Acute Parenchymatous 245 

Chronic Parenchymatous .... 249 

Interstitial 251 

Suppurative Interstitial 253 

Nitrogen, Determination of . . . . 213 

Nubecula 146 

O 

Oidium Lactis 182 

Oliguria 234 

Oliver's Test Papers 107 

Osteomalacia 239 

Oxalic Acid 72 

Oxaluric Acid 72 

21 



PAGE 

Oxybutyric Acid. 124 

Oxymandelic Acid 125 

P 

Parabanic Acid 72 

Paraglobuline 87 

Parasites 179 

Parenchymatous Nephritis 245 

Penicillium Glaucum 182 

Pentastoma Denticulatum 188 

Peptone 95 

Peritonitis 237 

Pettenkofers Test 137 

Phosphates 76 

Earthy 77, 161 

Triple 164 

Magnesium 163 

Calcium 163 

Phosphoric Acid 221 

Picric Acid Tests 100, 112 

Polyuria 233 

Pro-peptone 96 

Prostatitis 298 

Purpura Haemorrhagica 240 

Pus-Corpuscles 169 

Pyelitis 258 

Acute 259 

Chronic 261 

Pyelitis Calculosa 262 

Tuberculosa 264 

Q 

Qualitative Determination 224 

Key to 224 

Quantitative Determination .... 200 

Albumen 215 

Chlorine 219 

Creatinine 212 

Nitrogen 213 

Phosphoric Acid 221 

Solids 201 

Sugar 216 

Sulphuric Acid 223 

Urea 202 

Uric Acid 210 



322 



ALPHABETICAL INDEX. 



R 

PAGE 

Rachitis 239 

Reaction 46, 270 

Reagents 197 

Rhabdites Genitales 188 

S 

Saccharimeter 301 

Saccharomyces 181 

Salicylic Acid 145 

Sarcinse 181 

Scatol Derivatives 135 

Scurvy 240 

Sediment 146 

Classification of 150 

Skin-Diseases 240 

Solids 201 

Specific Gravity 37, 273 

Spectrum 46 

Spermatorrhoea 298 

Spermatozoa 183, 299 

Spinal Diseases 239 

Stokvis's Test (Indican) 69 

Strongylus Gigas 187 

Sugar 104 

Bottger's Test for 110 

Heller's Test 105 

Molisch's Test 311 

Mulder's Test 107 

Oliver's Test Papers 107 

Phenyl-hydrazin Test. 309 

Picric Acid Test 112 

Roberts's lest 109 

Trommer's Test 107 

Vogel's Test 118 

Quantitative Determination. . 216 

Sulphates 82 

Sulphuretted Hydrogen 143 

Sulphuric Acid 83 



PAGE 

Sulphuric Acid, Determination of 223 
Syntonin 194 

T 
Tyrosine 124, 158 

U 

Urate of Ammonium 152 

Urates 151 

Urea 49, 202 

Ureometer 210 

Urethra 28, 298 

Uric Acid 56, 154, 210 

Urine 35 

Amount 36 

Constituents of 35 

Consistence 41 

Excretion of 30 

Color 42 

Fluorescence 45 

Transparency 45 

Reaction 46 

Solids 38 

Specific Gravity 37 

Urinometer 37 

Urobiline 64 

Urochrome 66 

Uroerythrine 125 

Uroglaucine 66 

Uro-ha3matine 65 

Urophseine 65 

Uro-rosein 135 

Uroxanthine 66 

Uroxanthine Test 68 

Urrhodine 66 

X 

Xanthine 72 

Z 

Zoogloa 181 



THE END. 



mi 




PLATE I.— A. 

1. Epithelium from the straight tubes of the kidney. The cylindrical cells come from 
the part nearest the papilla, the others from the higher tubules (medullary rays). 
After long standing these become spherical. — 2. Epithelium from the kidney, 
pelvis, and ureters. — 3. Epithelium of the bladder. — 4. Epithelium of the pros- 
tate. — 5. Epithelium of Cowper's glands. 

PLATE I.— B. 

1. Epithelium of the male urethra. — 2. Epithelium of the female urethra. — 3. Epithe- 
lium of Littre's glands. Plate I., A, 4 and 5, and Plate I., B, 1 and 2, all 
represent the so-called cylindrical epithelium. — 4. Vaginal epithelium. 



PUT 




PLATE II.— A. 
Primary forms of uric-acid crystals, the so-called whetstone crystals. These are 
always colored as a native precipitate, but are rendered colorless by solution 
and reprecipitation. 

PLATE II.— B. 
Uric acid : the sediment as found in native urine ; rosettes, and lamellated crystals ; 
also the sharp crystals as found in pyelitis calculosa. 



PIM 




PLATE III.— A. 
1. Nitrate of urea, as seen when a drop of HN0 3 is allowed to flow under the cover-glass. 
Rhombic and hexagonal plates. — 2. Oxalate of calcium, as the native sediment 
of an acid urine. Tetragonal octahedrons and the so-called hour-glass forms. 

PLATE III.— B. 

Triple phosphate (NH 4 )M & P0 4 + 6H 2 0. The common coffin-lid crystals at the bottom 
of the figure, and above the fern-leaved crystals of the same, as seen when 
quickly precipitated by addition of ammonia. The crystals in the upper right- 
hand corner are crystals of phosphate of calcium, of the formula P0 4 HCa + 
2H 2 0, from a weakly acid urine, with a tendency to become alkaline. The 
triple phosphate is found in alkaline urine. 



PUT 




PLATE IV.— A. 

Leucine and tyrosine : sediment from acute yellow atrophy of the liver ; sheaves of 
tyrosine needles, and the drop-like forms of leucine, with small double spheres 
of ammonium urate. 

PLATE IV.— B. 

The sediment of alkaline fermentation : the coffin-lid triple phosphates ; the brown 
double spheres of ammonium urate, and the amorphous tribasic calcium phos- 
phates mixed with bacteria. 



KV 




PLATE V.— A. 
1. Haemin, or chloride of haematin, obtained by adding a grain of salt to the residue 
of a drop of urine evaporated on an object-glass, and then allowing a drop of 
acetic acid to flow under the cover. — 2. Blood-corpuscles of various forms, and 
a blood-cylinder. 

PLATE V.— B. 
Urate of sodium, the amorphous precipitate (sedimentum lateritium) ; also, the crys- 
tals of calcium oxalate and uric acid, together with fermentation fungi, which 
make up the sediment of a febrile urine. 



mm 




PLATE VII.— A. 
1. The massive fibrin cylinder. — 2. The granular cylinders. — 3. The hyaline cylinder. 
— 4. The waxy cylinders. — 5. Epithelial casts and cylinders. — 6. The uric-acid 
cylinders. 

PLATE VII.— B. 
1. The ordinary pus-corpuscles. — 2. Those with prolongations showing amoeboid 
movements. — 3. Corpuscles with their nuclei rendered distinct by adding acetic 
acid. — 4. Corpuscles as altered by chronic pyelitis. — 5. Corpuscles swollen by 
the action of carbonate of ammonium. 



PIML 




PLATE VIII.— A. 

1. Yeast fungi. — 2. Penicillum glaucura. — 3. Sarcina. — 1. Cyst of the echinococcus, 
with detached hooks. 

PLATE VIII.— B. 

1. Cancer elements, as seen in the sediment of medullary epithelial cancer of the blad- 
der. — 2. A fragment of cancerous villous tissue of seldom occurrence. — 3. Epi- 
thelial cells stripped from surface of villous cancer. 



REASONS WHY PHYSICIANS SHOULD 
SUBSCRIBE FOR THE 

I)ew York IQedical Journal, 

Edited by FRANK P. FOSTER, M. D., 



"DECAUSE : It is the LEADING JOURNAL of America, and contains more reading- 
-*-' matter than any other journal of its class. 

T) ECAUSE : It is the exponent of the most advanced scientific medical thought. 

"DECAUSE : Its contributors are among the most learned medical men of this country. 

"DECAUSE: Its "Original Articles" are the results of scientific observation and re- 
*-* search, and are of infinite practical value to the general practitioner. 

"DECAUSE: The "Reports on the Progress of Medicine," which are published from 
-^ time to time, contain the most recent discoveries in the various departments of 
medicine, and are written by practitioners especially qualified for the purpose. 

"DECAUSE : The column devoted in each number to " Therapeutical Notes " contains a 
■*-' resume of the practical application of the most recent therapeutic novelties. 

"DECAUSE : The Society Proceedings, of which each number contains one or more, 
-*-' are reports of the practical experience of prominent physicians who thus give to 
the profession the results of certain modes of treatment in given cases. 

"DECAUSE : The Editorial Columns are controlled only by the desire to promote the 
-^ welfare, honor, and advancement of the science of medicine, as viewed from a 
standpoint looking to the best interests of the profession. 

DECAUSE : Nothing is admitted to its columns that has not some bearing on medicine, 
** or is not possessed of some practical value. 

"DECAUSE : It is published solely in the interests of medicine, and for the upholding 
-^ of the elevated position occupied by the profession of America. 



The volumes begin with January and July of each year. Subscriptions 
can be arranged to begin with the volume. 



Subscription price, $5.00 per Annum. 

\ 



Journal of Cutaneous and Genito-Urinary Diseases - $2.50 ) Club rate, $7.00 
New York Medical Journal 5.00 f per annum. 



New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. 



JOURNAL OF 

CUTANEOUS AND GENITO-URINARY 

DISEASES. 

„,. , , ( Prince A. Morrow, A. M' M. D., and 

Edited by 1 T ^ ' ' 

( John A. Fordyce, M. D. 

Published Monthly by D. APPLETON <£ CO., 

1, 3, & 5 BOND STREET, NEW YORK. 



YVith the number for January, 1889, this Journal enters upon the seventh 
year of its publication. The history of the Journal has been one of progression, 
and, under the present editorial management, there can be no doubt that it will 
preserve and increase the reputation already established. 

Devoted to the diseases indicated in its title, the Journal will be contributed 
to by the most eminent dermatologists and syphilographers in this country. 
Whenever the subject requires illustration, woodcuts or chromo-lithographs will 
be employed. 

Letters from Europe, one or more of which will appear in each issue of the 
Journal, will keep the reader informed of the advances in this department of 
medicine at the great medical centers, Vienna, Berlin, and Paris. 

A feature of the Journal will be the publication of abstracts of translations 
of notable papers and selections from foreign journals. 

Due prominence will be given to Society Transactions, including papers read 
and the discussions had thereon, so far as they have a bearing upon the subjects 
to which the pages of the Journal are devoted. 

Both the editors and the publishers will put forth every effort to make the 
Journal instructive, attractive, and a representative one of its class; and they 
feel assured that every practitioner, whose work brings him in contact with 
cutaneous or genito-urinary diseases, will find it of great value and assistance 
to him. 



Subscription price, $2.50 per annum. 



New York Medical Journal .... $5.0C } Club rat ^ $ 7 00 

Journal of Cutaneous and Gen ito-Uri nary Dis- > 

eases $2.50 i per annum. 



Established by EDWARD L. YOUMANS. 



THE POPULAR SCIENCE 
MONTHLY, 

Edited by W. J. YOUMANS, 

Well known as a trustworthy medium for the spread of scientific truth in popu- 
lar form, is filled with articles of interest to everybody, by the ablest writers 
of the time. Its range of topics, which is widening with the advance of sci- 
ence, includes — 

SOCIAL AND DOMESTIC ECONOMY. 

POLITICAL SCIENCE, OB THE CONDUCT OF GOVERNMENT. 

SCIENTIFIC ETHICS; MENTAL SCIENCE AND EDUCATION. 

MAN'S ORIGIN AND DEVELOPMENT. 

RELATIONS OF SCIENCE AND RELIGION. 

PREVENTION OF DISEASE, AND IMPROVEMENT OF THE RACE. 

AGRICULTURE AND FOOD PRODUCTS. 

THE INDUSTRIAL ARTS. 

NATURAL HISTORY; DISCOVERY; EXPLORATION, ETC. 

With other ill u strati ods, each number contains a finely-engraved Portrait 
of some eminent scientist, with a Biographical Sketch. 

Among its recent contributors are : Herbert Spencer, Andrew D. White, David 
A. Wells, T. H. Huxley, Sir John Lubbock, Edward Atkinson, W. K. Brooks, 
Grant Allen, E. D. Cope, Thomas Hill, David Starr Jordan, Joseph Le Conte, 
Appleton Morgan, Felix L. Oswald, Sir William Dawson, F. W. Clarke, Horatio 
Hale, Edward S. Morse, J. S. Newberry, Eugene L. Eichards, 1ST. S. Shaler, D. 
G. Thompson. 



WHAT IS SAID OF THE MONTHLY. 



"'The Popular Science Monthly 1 has long 1 since 
taken its place as the one magazine which deals with 
science in a popular manner. In this respect it cer- 
tainly has no rival and no peer. That it is not too 
solid for a large and growing body of readers its 
prosperity demonstrates." — New York, Tribune. 

'"The Popular Science Monthly 1 is devoted to 
nothing except Truth as far as it has yet been dis- 
covered—Truth at all hazards, and irrespective of 
consequences. ... To thoughtfully read ' The Popu- 
lar Science Monthly 1 is to have mastered at least the 
rudiments of the largest education that has yet 
been attained on earth."— New York Mail and Ex- 



"This magazine has made a field for itself, in 
which it stands alone. It has done more to popu- 
larize science than all other publications added to- 
gether, and well deserves the marked success which 
it has attained.' 1 — The Republic (Washington). 

"There is no diminution in the excellence of 
this magazine since Prof. Youmans's death. It is 
well established, and has the highest fame for a work 
of its kind."— .Bosfcm Herald. 

" The magazine is as trenchant, progressive, thor- 
oughly informed, and full of ability as it ever was.' 1 
— Utica(N.Y.) Herald. 

" ' The Popular Science Monthly ? can not be ex- 
cel led."— Hartford (Conn .) Evening Post. 



New York : D. APPLETON & COMPANY, 1, 3, & 5 Bond Street. 
Single Number, 50 cents. Yearly Subscription, $5.00. 



LECTURES UPON DISEASES OF THE REC- 
TUM AND THE SURGERY OF THE 
LOWER BOWEL. 

Delivered at the Bellevue Hospital Medical College by W. H. Van Buren, M. D., 
late Professor of the Principles and Practice of Surgery in the Bellevue 
Hospital Medical College, etc., etc. 



Second edition, revised and enlarged. One volume, 8vo, 412 pages, with 27 Illustrations 
and complete Index. Cloth, $3.00 ; sheep, $4.00. 



"The reviewer too often finds it a difficult task to discover points to praise, in order 
that his criticisms may not seem one-sided and unjust. These lectures, however, place 
him upon the other horn of the dilemma, viz., to find somewhat to criticise severely enough 
to clear himself of the charge of indiscriminating laudation. Of course, the author upholds 
some views which conflict with other authorities, but he substantiates them by the most 
powerful of arguments, viz., a large experience, the results of which are enunciated by 
one who elsewhere shows that he can appreciate, and accord the due value to, the work 
and experience of others." — Archives of Medicine. 

" The present is a new volume rather than a new edition. Both its size and material 
are vastly beyond its predecessor. The same scholarly method, the same calm, convincing 
statement, the same wise, carefully matured counsel, pervade every paragraph. The dis- 
comfort and dangers of the diseases of the rectum call for greater consideration than they 
usually receive at the hands of the profession." — Detroit Lancet. 

A PRACTICAL TREATISE ON THE SURGICAL 

DISEASES OF THE GENITO-URINARY 

ORGANS, INCLUDING SYPHILIS. 

Designed as a Manual for Students and Practitioners. "With Engravings and 
Cases. By W. H. Van Buren, A. M., M. D., late Professor of Principles 
of Surgery, with Diseases of the Genito-Urinary System and Clinical Surgery, 
in Bellevue Hospital Medical College, etc., and E. L. Keyes, A. M., M. D., 
Professor of Dermatology in Bellevue Hospital Medical College; Surgeon 
to the Charity Hospital, Venereal Diseases, etc. 



One volume, 8vo, 672 pages. Cloth, $5.00 ; sheep, $6.00. 



This work is really a compendium of, and a book of reference to, all modern works 
treating in any way of the surgical diseases of the genito-urinary organs. At the same 
time, no other single book contains so large an array of original facts concerning the 
class of diseases with which it deals. These facts are largely drawn from the extensive 
and varied experience of the authors. 

Many important branches of genito-urinary diseases, as the cutaneous maladies of 
the penis and scrotum, receive a thorough and exhaustive treatment that the professional 
reader will search for elsewhere in vain. 

The subject of syphilis is included, of necessity, in this treatise. Although properly 
belonging to the department of Principles of Surgery, there is no disease falling within 
the limits of this work concerning which clear and correct ideas as to nature and treat- 
ment will, at the present time, so seriously influence success in practice. 

The work is elegantly and profusely illustrated, and enriched by fifty-five original 
cases, setting forth obscure and difficult points in diagnosis and treatment. 



New York: D. APPLETON & CO., 1, 3, & 5 Bond Street 



A MANUAL OF OPERATIVE SURGERY, 

By JOSEPH D. BRYANT, M. D., 

Professor of Anatomy and Clinical Surgery, and Associate Professor of Orthopaedic Surgery in 

Bellevue Hospital Medical College ; Visiting Surgeon to Bellevue and St. Vincent's Hos- 

pitals, and. Consulting Surgeon to the New York Lunatic Asylum, etc. 



NEW EDITION, REVISED AND ENLARGED. 

8vo, 530 pages and 793 Illustrations. Cloth, $5.00 ; sheep, $6.00. 



We invite the attention of students and practitioners of medicine to the 
following opinions aud notices of this sterling work: 

Dr. J. Willistox "Wright, Professor of Surgery in the Medical Department of the Uni- 
versity of the City of New York, and in the Medical Department of the University of 
Vermont, writes: 

" The concise and systematic maimer in which the accomplished author has treated the 
subject meets my hearty approval ; and as a book, fully up to the times in whatever the 
crucial test of experience has assigned a. definite place in our art, should commend itself 
alike to students and practitioners of medicine and surgery." 

Dr. Roswell Park, Professor of the Principles and Practice of Surgery and Clinical 
Surgery in the Medical Department of the University of Buffalo, writes : 

" . . . It is, according to my notion, the best work of its kind now before the public, 
and I shall take great pleasure, not only in commending it to others, but in making it my 
own guide. ..." 

Dr. C. T. Parkes, Professor of Surgery in Rush Medical College, Chicago, writes : 

" It gives me great pleasure to express my opinion of the excellence of Dr. Bryant's 
' Manual of Operative Surgery.' For clearness of description, precision of statement/order 
in the arrangement of subjects, and faithfulness in illustration, the work surpasses anything 
of the kind in my possession." 

"... "We know of no better work on operative surgery to place in the hands of the 
student or of the young surgeon. . . ." — Medical Record. 

"... "We can recommend this book with confidence, both to advanced students and 
practicing surgeons; we have seen nothing of the kind we like so well." — Canadian Prac- 
titioner. 

" This work by Dr. Bryant, one of the foremost surgeons of New York, is a credit to our 
country and profession. The book is of a handy size, and printed from good, clear type, 
and yet. with these advantages, it has not been condensed so as to deprive it of the value of 
the most complete work on operative surgery. In addition to the author's clear and forcible 
style, we find everything splendidly illustrated that could in any sense of the word require 
illustrating." — Southern Clinic. 

" It is the character of book that everv surgeon needs for readv reference, since it is not 
always that one has time to refer to more comprehensive works, or to atlases. It is especially 
useful for physicians in the countrv. who have not the amount of surgical practice required 
to keep them familiar with the entire field of operation."— American Practitioner and News. 

" The author of this work seems to know how, in the briefest space, to give the student 
of surgery the aid necessary 'to acquire established facts,' and this is an important point in 
a book of this kind. The text is most fully illustrated, and brings the subject to date." — 
New Fork Medical Times. 

New York: D. APPLETON & CO., 1, 3, & 5 Bond Street. 



A TEXT-BOOK ON SURGERY: 

GENERAL, OPERATIVE, AND MECHANICAL 

By JOHN A. WYETH, M. D., 
Professor of Surgery in the New York Polyclinic ; Surgeon to Mount Sinai Hospital, etc. 

Price, Buckram, uncut edges, $7.00; Sheep, $8.00; Half Morocco, $8.50. 



SOLD BY SUBSCRIPTION ONLY. 



This work, consisting of seven hundred and sixty-nine pages, and containing seven 
hundred and seventy-one illustrations, of which about fifty are colored, is one of the most 
beautiful and unique, and at the same time one of the most complete, works on general 
surgery ever published. 

It is printed in clear, large type on a superior quality of paper, and the book, large 
without being bulky, is in a shape to be easily handled. The illustrations are executed 
with especial reference to the accurate anatomy of the parts represented ; the relations of 
bones, muscles, nerves, and vessels to adjacent structures ; and lines of incision are indi- 
cated in operations about the joints and articulations, thus explaining and simplifying 
their descriptions in the text. The colored illustrations which depict the more important 
operations, especially with reference to the large arteries, constitute a novel and very im- 
portant feature of the work. 

The following brief synopsis will convey an idea of the plan of the work : 

As a preliminary to the consideration of the various operations the author thoroughly 
-~ r ^s the methods of preparing the different antiseptic surgical dressings, ligatures, 
sutures, solutions, drains ; the materials for bandaging, with illustrated instructions as to 
the manner of applying bandages in the various forms employed in different parts of the 
body • anaesthesia, both local and general, including the employment of cocaine as a local 
anaesthetic; the use and method of administering ether and chloroform; instruments and 
their uses ; baemostasis and the after-treatment of cae 

Inflammation, its causes and methods of treatment ; wounds and the manner of closing 
them; transfusion, poisoned wounds, burns and scalds, gangrene, and the various surgical 
lesions are thoroughly considered and their appropriate treatment given. 

Amputations, with full and minute details* of the manner of performing them, and the 
different methods employed, constitute an important chapter in the book. All the prin- 
cipal operations are illustrated by colored engravings made from direct tracings of frozen 
sections on the cadaver. 

The section devoted to the arteries and the procedures necessary in legating them is 
one of the most important and most beautifully illustrated portions of the work. The 
woodcuts showing the relation of the parts involved in tying the important arteries are 
colored, and their anatomy is depicted in a wonderfully clear and accurate manner. 

Surgical diseases and surgery of the bones; surgery of the articulations, regional 
surgery, including the common operations on the eye. ear. and jaws ; tumors about the 
neck, "thyreotomy, laryngotomy, tracheotomy, and cesophagotoniy ; the surgery of the 
thorax and abdomen ; and operations on the rectum and anus are dealt with in the light 
of the most advanced surgical knowledge. 

Genito-urinary surgery and specific lesions receive a due share of attention, as do de- 
formities of the spine and* extremities, and malignant tumors and growths. 

Thi3 work, written by an accomplished surgeon of wide experience, and fully abreast 
of the highest attainments in surgical knowledge and science, presents to the student and 
practitioner a means of acquainting himself with modern surgery as it is taught and prac- 
ticed by a master of the art, and will enable him to prepare himself for the intelligent 
performance of many operations, and to treat many surgical lesions with which he may 
feel he is not sufficiently familiar. 

D. APPLETON & CO., Publishers, 

1, 3, & 5 BOND ST., NEW YORK. 



Mwch, 1889. 



MEDICAL 



HYGIENIC WORKS 



PUBLISHED BY 



D. APPLETON & CO., 1, 3, & 5 Bond Street, New York. 



BARKER (FORDYCE). On Sea-Sickness. A Popular Treatise for Travelers 
and the General Reader. Small 12mo. Cloth, 75 cents. 

BARKER (FORDYOE). On Puerperal Disease. Clinical Lectures delivered at 
Bellevue Hospital. A Course of Lectures valuable alike to the Student and 
the Practitioner. Third edition. 8vo. Cloth, $5.00 ; sheep, $6.00. 

BARTHOLOW (ROBERTS). A Treatise on Materia Medica and Therapeutics. 
Sixth edition. Revised, enlarged, and adapted to " The New Pharmacopoeia." 
8vo. Cloth, $5.00; sheep, $6.00. 

BARTHOLOW (ROBERTS). A Treatise on the Practice of Medicine, for the 
Use of Students and Practitioners. Sixth edition, revised and enlarged. 8vo 
Cloth, $5.00; sheep, $6.00. 

BARTHOLOW (ROBERTS). On the Antagonism between Medicines and be- 
tween Remedies and Diseases. Being the Cartwright Lectures for the Year 
1880. 8vo. Cloth, $1.25. 

BASTIAN (H. CHARLTON). Paralysis : Cerebral, Bulbar, and Spinal. Illus- 
trated. Small 8vo. Cloth, $4.50. 

BASTIAN (H. CHARLTON). The Brain as an Organ of the Mind. 12mo. 
Cloth, $2.50. 

BELLEVUE and CHARITY HOSPITAL REPORTS. Edited by W. A. Ham- 
mond, M. D. 8vo. Cloth, $4.00. 

BENNET (J. H.). On the Treatment of Pulmonary Consumption, by Hygiene, 
Climate, and Medicine. Thin 8vo. Cloth, $1.50. 

BILLINGS (F. S.). The Relation of Animal Diseases to the Public Health, and 
their Prevention. 8vo. Cloth, $4.00. 

BILLROTH (THEODOR). General Surgical Pathology and Therapeutics. A 
Text-Book for Students and Physicians. Translated from the tenth German 
edition, by special permission of the author, by Charles E. Hackley, M. D. 
Fifth American edition, revised and enlarged. 8vo. Cloth, $5.00; sheep, $6.00. 

BRAMWELL (BYROM). Diseases of the Heart and Thoracic Aorta. Illus- 
trated with 226 Wood-Engravings and 68 Lithograph Plates — showing 91 
Figures— in all 317 Illustrations. 8vo. Cloth, $8.00; sheep, $9.00. 

BRYANT (JOSEPH D.). A Manual of Operative Surgery. New edition, revised 
and enlarged. 793 Illustrations. 8vo. Cloth, $5.00 ; sheep, $6.00. 



BUCK (GURDON). Contributions to Reparative Surgery, showing its Applica- 
tion to the Treatment of Deformities produced by Destructive Disease or 
Injury; Congenital Defects from Arrest or Excess of Development; and 
Cicatricial Contractions following Burns. Illustrated by Thirty Cases and 
fine Engravings. 8vo. Cloth, $3.00. 

BURT (STEPHEN SMITH). Exploration of the Chest in Health and Disease. 
{In press.) 

CAMPBELL (F. R.). The Language of Medicine. A Manual giving the Origin, 
Etymology, Pronunciation, and Meaning of the Technical Terms found in 
Medical Literature. 8vo. Cloth, $3.00. 

CARPENTER (W. B.). Principles of Mental Physiology, with their Applica- 
tion to the Training and Discipline of the Mind, and the Study of its Morbid 
Conditions. 12mo. Cloth, $3.00. 

CARTER (ALFRED H.). Elements of Practical Medicine. Third edition, re- 
vised and enlarged. 12mo. Cloth, $3.00. 

CASTRO (D'OLIVEIRA). Elements of Therapeutics and Practice according 
to the Dosimetric System. 8vo. Cloth, $4.00. 

COOLEY. Cyclopaedia of Practical Receipts, and Collateral Information in the 
Arts, Manufactures, Professions, and Trades, including Medicine, Pharmacy, 
and Domestic Economy. Designed as a Comprehensive Supplement to the 
Pharmacopoeia, and General Book of Reference for the Manufacturer, Trades- 
man, Amateur, and Heads of Families. Sixth edition, revised and partly re- 
written by Richard V. Tuson. With Illustrations. 2vols.,8vo. Cloth, $9.00. 

CORNING (J. L.). Brain Exhaustion, with some Preliminary Considerations 
on Cerebral Dynamics. Crown 8vo. Cloth, $2.00. 

CORNING (J. L.). Local Anaesthesia in General Medicine and Surgery. Being 
the Practical Application of the Author's Recent Discoveries. With Illus- 
trations. Small 8vo. Cloth, $1.25. 

ELLIOT (GEORGE T.). Obstetric Clinic : A Practical Contribution to the Study 
of Obstetrics aud the Diseases of Women and Children. 8vo. Cloth, $4.50. 

EVANS (GEORGE A.). Hand-Book of Historical and Geographical Phthisi- 
ology. With Special Reference to the Distribution of Consumption in the 
United States. 8vo. Cloth, $2.00. 

E VETZKY (ETIENNE). The Physiological and Therapeutical Action of Ergot. 
Being the Joseph Mather Smith Prize Essay for 1881. 8vo. Limp cloth, $1.00. 

FLINT (AUSTIN). Medical Ethics and Etiquette. Commentaries on the 
National Code of Ethics. 12mo. Cloth, 60 cents. 

FLINT (AUSTIN). Medicine of the Future. An Address prepared for the 
Annual Meeting of the British Medical Association in 1886. With Portrait 
of Dr. Flint. 12mo. Cloth, $1.00. 

FLINT (AUSTIN, Jr.). Text-Book of Human Physiology; designed for the 
Use of Practitioners and Students of Medicine. Illustrated with three 
hundred and sixteen W r oodcuts and Two Plates. Fourth edition, revised. 
imperial 8vo. Cloth, $6.00 ; sheep, $7.00. 

FLINT (AUSTIN Jr.). The Physiological Effects of Severe and Protracted 
Muscular Exercise; with Special Reference to its Influence upon the Excre- 
tion of Nitrogen. 12mo. Cloth. $1.00. 



3 

FLINT (AUSTIN", Je.). Physiology of Man. Designed to represent the Exist- 
ing State of Physiological Science as applied to the Functions of the Human 
Body. Complete in 5 vols., 8vo. Per vol., cloth, $4.50 ; sheep, $5.50. 

*** Vols. I and II can be had in cloth and sheep binding ; Vol. Ill in sheep 
only. Vol. IV is at present out of print. 

FLINT (AUSTIN, Je.). The Source of Muscular Power. Arguments and Con- 
clusions drawn from Observation upon the Human Subject under Conditions 
of Rest and of Muscular Exercise. 12mo. Cloth, $1.00. 

FLINT (AUSTIN, Je.). Manual of Chemical Examinations of the Urine in 
Disease ; with Brief Directions for the Examination of the most Common 
Varieties of Urinary Calculi. Revised edition. 12mo. Cloth, $1.00. 

FOSTER (FRANK P.). Illustrated Encyclopaedic Medical Dictionary, being 
a Dictionary of the Technical Terms used by "Writers on Medicine and the 
Collateral Sciences in the Latin, English, French, and German Languages. 
This work will be completed in four volumes. {Sold by subscription only.) 
Volume one now ready. 8vo. Sheep, $10.00 ; half morocco, $11.00. 

FOTHERGILL (J. MILNER). Diseases of Sedentary and Advanced Life. 
8vo. Cloth, $2.00. 

FOURNIER (ALFRED). Syphilis and Marriage. Translated by P. Albert 
Morrow, M. D. 8vo. Cloth, $2.00; sheep, $3.00. 

FREY (HEINRICH). The Histology and Histochemistry of Man. A Treatise 
on the Elements of Composition and Structure of the Human Body. Trans- 
lated from the fourth German edition by Arthur E. J. Barker, M. D., and 
revised by the author. With 608 Engravings on Wood. 8vo. Cloth, $5.00 ; 
sheep, $6.00. 

FRIEDLANDER (CARL). The Use of the Microscope in Clinical and Patho- 
logical Examinations. Second edition, enlarged .and improved, with a 
Chromo-lithograph Plate. Translated, with the permission of the author, 
by Henry C. Coe, M. D. 8vo. Cloth, $1.00. 

GARMANY (JASPER J.). Operative Surgery on the Cadaver. With Two 
Colored Diagrams showing the Collateral Circulation after Ligatures of 
Arteries of Arm, Abdomen, and Lower Extremity. Small 8vo. Cloth, 
$2.00. 

GERSTER (ARPAD G.). The Rules of Aseptic and Antiseptic Surgery. 
A Practical Treatise for the Use of Students and the General Practitioner. 
Illustrated with over two hundred fine Engravings. 8vo. Cloth, $5.00 ; 
sheep, $6.00. 

GROSS (SAMUEL W.). A Practical Treatise on Tumors of the Mammary 
Gland. Illustrated. 8vo. Cloth, $2.50. 

GUTMA NN (EDWARD). The Watering-Places and Mineral Springs of Ger- 
many, Austria, and Switzerland. Illustrated. 12mo. Cloth, $2.50. 

GYNECOLOGICAL TRANSACTIONS. 8vo. Cloth, per volume, $5.00. 

Vol. VIII. Being the Proceedings of the Eighth Annual Meeting of the 

American Gynaecological Society, held in Philadelphia, 

September 18, 19, and 20, 1883. 
Vol. IX. Being the Proceedings of the Ninth Annual Meeting of the 

American Gynaecological Society, held in Chicago, Septem 

ber 30, and October 1 and 2, 1884. 
Vol. X. Being the Proceedings of the Tenth Annual Meeting of the 

American Gynaecological Society, held in Washington, D. 0., 

September 22, 23, and 24, 1885. 



GYNAECOLOGICAL TRANSACTIONS. 8vo. Cloth, per volume, $5.00. 

Vol. XI. Being the Proceedings of the Eleventh Annual Meeting of the 
American Gynaecological Society, held in Baltimore, Marv- 
land, September, 21, 22, and 23, 1886 

Vol. XII. Being the Proceedings of the Twelfth Annual Meeting of the 
American Gynaecological Society, held in New York, Tues- 
day, Wednesday, and Thursday, September 13, 14, and 15, 
1887. 

HAMMOND (W. A.). A Treatise on Diseases of the Nervous System. Eighth 
edition, rewritten, enlarged, and improved. 8vo. Cloth, $5.00; sheep, $6.00. 

HAMMOND (W. A.). A Treatise on Insanity, in its Medical Relations. 8vo. 
Cloth, $5.00; sheep, $6.00. 

HAMMOND (W. A.). Clinical Lectures on Diseases of the Nervous System. 
Delivered at Bellevue Hospital Medical College. Edited bv T. M. B. Cross, 
M. D. 8vo. Cloth, $3.50. 

HARVEY (A.). First Lines of Therapeutics. 12mo. Cloth, $1.50. 

HOFFMANN-ULTZMANN. Analysis of the Urine, with Special Reference 
to Diseases of the Urinary Apparatus. By M. B. Hoffmann, Professor in 
the University of Gratz; and R. Ultzmann, Tutor in the University of 
Vienna. Second enlarged and improved edition. 8vo. Cloth, $2.00. 

HOWE (JOSEPH W.). Emergencies, and how to treat them. Fourth edition, 
revised. 8vo. Cloth, $2.50. 

HOWE (JOSEPH W.). The Breath, and the Diseases which give it a Fetid 
Odor. With Directions for Treatment. Second edition, revised and corrected. 
12mo. Cloth, $1.00. 

HUEPPE (FERDINAND). The Methods of Bacteriological Investigation. 
Written at the request of Dr. Robert Koch. Translated by Hermann M. 
Biggs, M. D. Illustrated. 8vo. Cloth, $2.50. 

JACCOUD (S.). The Curability and Treatment of Pulmonary Phthisis. Trans- 
lated and edited by Montagu Lubbock, M. D. 8vo. Cloth, $4.00. 

JONES (H. MACNAUGHTON). Practical Manual of Diseases of Women and 
Uterine Therapeutics. For Students and Practitioners. 188 Illustrations. 
12mo. Cloth, $3.00. 

JOURNAL OF CUTANEOUS AND GENITO-URINARY DISEASES. 
Published Monthly. Edited by Prince A. Morrow, A. M., M. D., and John 
A. Fordyce, M. D. Price, $2.50 per annum, or, if taken in connection with 
the " New York Medical Journal " ($5.00 per annum), the two publications 
will be furnished at $7.00 per annum. 

KEYES (E. L.). A Practical Treatise on Genito-Urinary Diseases, including 
Syphilis. I3eing a new edition of a work with the same title, by Van Buren 
and Keyes. Almost entirely rewritten. 8vo. With Illustrations. Cloth, 
$5.00 ; sheep, $6.00. 

KEYES (E. L.). The Tonic Treatment of Syphilis, including Local Treatment 
of Lesions. 8vo. Cloth, $1.00. 

KHSTGSLEY (N. W.). A Treatise on Oral Deformities as a Branch of Mechanj- 
cal Surgery. With over 350 Illustrations. 8vo. Cloth, $5.00; sheep, $6.00. 

LEGG (J. WICK HAM). On the Bile, Jaundice, and Bilious Diseases. With 
Illustrations in Ohromo-Lithography. 8vo. Cloth, $6.00 ; sheep, $7.00. 






LITTLE (W. J.). Medical and Surgical Aspects of In-Knee (Genu-Vaigum; : 
its Relation to Rickets, its Prevention, and its Treatment, with and without 
Surgical Operation. Illustrated by upward of Fifty Figures and Diagram*. 
8vo. Cloth, $2.00. 

LORING (EDWARD G.). A Text-Book of Ophthalmoscopy. Part I. The 
Normal Eye, Determination of Refraction, and Diseases of the Media. With 
131 Illustrations, and 4 Ghromo-Lithographs. 8vo. Cloth, $5.00. 

LUSK (WILLIAM T.). The Science and Art of Mid wifery. With 246 Illustra- 
tions. Second edition, revised and enlarged. 8vo. Cloth, $5.00; sheep, $6.00. 

LUYS (J.). The Brain and its Functions. With Illustrations. 12mo. Cloth, 
$1.50. 

MARKOE (T. M.). A Treatise on Diseases of the Bones. With Illustrations. 
8vo. Cloth, $4.50. 

MAUDSLEY (HENRY). Body and Mind : an Inquiry into their Connection 
and Mutual Influence, specially in reference to Mental Disorders. An 
enlarged and revised editioD, to which are added Psychological Essays. 
12mo. Cloth, $1.50. 

MAUDSLEY (HENRY). Physiology of the Mind. Being the first part of a 
third edition, revised, enlarged, and in great part rewritten, of " The Phys- 
iology and Pathology of the Mind." 12ino. Cloth, $2.00. 

MAUDSLEY (HENRY). Pathology of the Mind. Third edition. 12mo. Cloth, 

$2.00. 

MAUDSLEY (HENRY). Responsibility in Mental Disease. 12nio. Cloth, 

$1.50. 

NEFTEL (WM. B.). Galvano-Therapeutics. The Physiological and Therapeuti- 
cal Action of the Galvanic Current upon the Acoustic, Optic, Sympathetic, 
and Pneumogastric Nerves. 12mo. Cloth, $1.50. 

NEUMANN (rSIDOR). Hand-Book of Skin Diseases. Translated by Lucius 
D. Bulkley, M. D. Illustrated by 6Q Wood-Engravings. 8vo. Cloth, 
$4.00 ; sheep, $5.00. 

THE NEW YORK MEDICAL JOURNAL (weekly). Edited by Frank P. 
Foster, M. D. Terras per annum, $5.00, or, if taken in connection with the 
Journal of Cutaneous and Genito-Urinary Diseases ($2.50 per annum), the 
two publications will be supplied at $7.00 per annum. 
Binding Cases, cloth, 50 cents each. 

General Index, from April, 1865, to June, 1876 (23 vols.) 8vo. Cloth, 75 
cents. 

THE NEW YORK MEDICAL JOURNAL VISITING-LIST AND COM- 
PLETE POCKET ACCOUNT-BOOK. Prepared by Charles H. Shears, 
M.D. $1.25. 

NIE MEYER (FELIX VON). A Text-Book of Practical Medicine, with particu- 
lar reference to Physiology and Pathological Anatomy. Containing all the 
author's Additions and Revisions in the eighth and last German edition. 
Translated by George H. Humphreys, M. D., and Charles E. Hackley, M. D. 
2 vols., 8vo. Cloth, $9.00; sheep, $11.00. 

NIGHTINGALE'S (FLORENCE) Notes on Nursing. 12mo. Cloth, 75 cents. 



6 

PEASLEE (E. R.). A Treatise on Ovarian Tumors: their Pathology, Diagnosis, 
and Treatment, with reference especially to Ovariotomy. With Illustra- 
tions. 8vo. Cloth, $5.00 ; sheep, $6.00. 

PEREIRA'S (Dr.) Elements of Materia Medica and Therapeutics. Abridged 
and adapted for the Use of Medical and Pharmaceutical Practitioners and 
Students, and comprising all the Medicines of the British Pharmacopoeia, 
with such others as are frequently ordered in Prescriptions, or required by 
the Physician. Edited by Robert Bentley and Theophilus Redwood. Royal 
8vo. Cloth, $7.00; sheep, $8.00. 

PEYER (ALEXANDER). An Atlas of Clinical Microscopy. Translated and 
edited by Alfred C. Girard, M. D. First American, from the manuscript 
of the second German edition, with Additions. Ninety Plates, with 105 
Illustrations, Chromo-Lithographs. Square 8vo. Cloth, $6.00. 

POMEROY (OREN D.). The Diagnosis and Treatment of Diseases of the Ear. 
With One Hundred Illustrations. Second edition, revised and enlarged. 8vo. 
Cloth, $3.00. 

POORE (C. T.). Osteotomy and Osteoclasis, for the Correction of Deformities 
of the Lower Limbs. 50 Illustrations. 8vo. Cloth, $2.50. 

QUA1N (RICHARD). A Dictionary of Medicine, including General Pathology, 
General Therapeutics, Hygiene, and the Diseases peculiar to Women and 
Children. By Various Writers. Edited by Richard Quain, M. D., In one 
large 8vo volume, with complete Index, and 138 Illustrations. (Sold only 
uy subscription.) Half morocco, $8.00. 

RANNEY (AMBROSE L.). Applied Anatomy of the Nervous System, being a 
Study of this Portion of the Human Body from a Standpoint of its General 
Interest and Practical Utility, designed for Use as a Text-Book and as a Work 
of Reference. Second edition, revised and enlarged. Profusely illustrated. 8vo. 
Cloth, $5.00; sheep, $6.00. 

RANNEY" (AMBROSE L.). Lectures on Electricity in Medicine, delivered at 
the Medical Department of the University of Vermont, Burlington. Nu- 
merous Illustrations. 12mo. Cloth, $1.00. 

RANNEY (AMBROSE L.). Practical Suggestions respecting the Varieties of 
Electric Currents and the Uses of Electricity in Medicine, with Hints relat- 
ing to the Selection and Care of Electrical Apparatus. With Illustrations 
and 14 Plates. 16mo. Cloth, $1.00. 

ROBINSON (A. R.). A Manual of Dermatology. Revised and corrected. 8vo. 
Cloth, $5.00 

ROSCOE-SCHORLEMMER. Treatise on Chemistry. 
Vol. 1. Non-Metallic Elements. 8vo. Cloth, $5.00. 
Vol. 2. Part I. Metals. 8vo. Cloth, $3.00. 
Vol. 2. Part II. Metals. 8vo. Cloth, $3.00. 
Vol. 3. Part I. The Chemistry of the Hydrocarbons and their Derivatives. 

8vo. Cloth, $5.00. 
Vol. :;. Pari II. The Chemistry of the Hydrocarbons and their Derivatives. 

Cloth, $5.00. 
Vol. :;. Partlll. The Chemistry of the Hydrocarbons and their Deriva- 
tives. 8vo. Cloth, $3.00. 



ROSCOE-SCHORLEMMER. Treatise od Chemistry. 

Vol. 3. Part IV. This part includes a description of the Aromatic Com- 
pounds containing seven atoms of Carbon. The first portion is concerned 
with the Toluene Group, then come the Benzyl, Benzoyl, and Hydrobenzil 
Groups, and lastly the Xylene Group of eight Carbon Compounds. 
Cloth, $3.00. 

ROSENTHAL (I.). General Physiology of Muscles and Nerves. With 75 Wood- 
cuts. 12mo. Cloth, $1.50 

S AYRE (LEWIS A.). Practical Manual of the Treatment of Club-Foot. Fourth 
edition, enlarged and corrected. 12mo. Cloth, $1.25. 

SAYRE (LEWIS A.). Lectures on Orthopedic Surgery and Diseases of the 
Joints, delivered at Bellevue Hospital Medical College. Xew edition, illus- 
trated with 324 Engravings on Wood. 8vo. Cloth, $5.00 ; sheep, $6.00. 

SCHROEDER (KARL). A Manual of Midwifery, including the Pathology of 
Pregnancy and the Puerperal State. Translated into English from the third 
German edition, by Charles H. Carter, M. D. With 26 Engravings on Wood. 
8vo. Cloth, $3.50 ; sheep, $4.50. 

SCHULTZE (B. S.). The Pathology and Treatment of Displacements of the 
Uterus. Translated from the German by Jameson J. Macan, M. A., etc ; 
and edited by Arthur V. Macan, M. B., etc. With One Hundred and 
Twenty Illustrations. 8vo. Cloth, $3.50. 

SHOEMAKER (JOHN V.). A Text-Book of Diseases of the Skin. Six 
Chromo-Lithographs and numerous Engravings. 8vo. Cloth, $5.00; sheep, 
$6.00. 

SIMPSON (JAMES Y.). Selected Works: Anaesthesia, Diseases of Women. 
3 vols., 8vo. Per volume. Cloth, $3.00; sheep, $4.00. 

SKENE (ALEXANDER J. C). A Text-Book on the Diseases of Women. 
Illustrated with two hundred and fifty-four Illustrations, of which one 
hundred and sixty -five are original, and nine chromo-lithographs. {Sold by 
subscription only.) 8vo. Cloth, $6.00 ; sheep, $7.00. 

SMITH (EDWARD). Foods. 12mo. Cloth, $1.75. 

SMITH (EDWARD). Health: A Hand-Book for Households and Schools. 
Illustrated. 12mo. Cloth, $1.00. 

STEINER (JOHANNES). Compendium of Children's Diseases : a Hand-Book 
for Practitioners and Students. Translated from the second German edition, 
by Lawson Tait. 8vo. Cloth, $3.50 ; sheep, $4.50. 

STEVENS (GEORGE T.) Functional Nervous Diseases: their Causes and 
theii Treatment. Memoir for the Concourse of 1881-1883, Academie Royal 
de Medecine de Belgique. With a Supplement, on the Anomalies of Re- 
fraction and Accommodation of the Eye, and of the Ocular Muscles. Small 
8vo. With six Photographic Plates and twelve Illustrations. Cloth, $2.50. 

STONE (R. FRENCH). Elements of Modern Medicine, including Principles ot 
Pathology and of Therapeutics, with many Useful Memoranda and Valuable 
Tables of Reference. Accompanied by Pocket Fever Charts. Designed for 
the Use of Students and Practitioners of Medicine. In wallet-book form, 
with pockets on each cover for Memoranda, Temperature Charts, etc. 
Roan, tuck, $2.50. 

STRECKER (ADOLPH). Short Text-Book of Organic Chemistry. By Dr. 
Johannes Wislicenus. Translated and edited, with Extensive Additions, by 
W. H. Hodgkinson and A. J. Greenaway. 8vo. Cloth, $5.00. 

STRUMPELL (ADOLPH). A Text-Book of Medicine, for Students and Prac- 
titioners. With 111 Illustrations. 8vo. Cloth, $6.00; sheep, $7.00. 



SWANZY (HENRY R.). A Hand-Book of the Diseases of the Eye, and their 
Treatment. With 122 Illustrations, and Holmgren's Tests for Color-Blind- 
ness. Crown 8vo. Cloth, $3.00. 

TRACY (ROGER S.). The Essentials of Anatomy, Physiology, and Hygiene. 
12mo. Cloth, $1.25. 

TRACY (ROGER S.). Hand-Book of Sanitary Information for Householders. 
Containing Facts and Suggestions about Ventilation, Drainage, Care of Con- 
tagious Diseases, Disinfection, Food, and Water. With Appendices on Dis- 
infectants and Plumbers 1 Materials. 16mo. Cloth, 50 cents. 

TRANSACTIONS OF THE NEW YORK STATE MEDICAL ASSOCIA- 
TION. VOL. I. Being the Proceedings of the First Annual Meeting of the 
New York State Medical Association, held in New York, November 18, 19, 
and 20, 1884. Small 8vo. Cloth, $5.00. 

TYNDALL (JOHN). Essays on the Floating Matter of the Air, in Relation to 
Putrefaction and Infection. 12mo. Cloth, $1.50. 

ULTZMANN (ROBERT). Pyuria, or Pus in the Urine, and its Treatment. 
Translated by permission, by Dr. Walter B. Piatt. 12mo. Cloth, $1.00. 

VAN BUREN (W. H.). Lectures upon Diseases of the Rectum, and the Sur- 
gery of the Lower Bowel, delivered at Bellevue Hospital Medical College. 
Second edition, revised and enlarged. 8vo. Cloth, $3.00; sheep, $4.00. 

VAN BUREN (W. H.). Lectures on the Principles and Practice of Surgery. 
Delivered at Bellevue Hospital Medical College. Edited by Lewis A. Stim- 
son, M. D. 8vo. Cloth, $4.00 ; sheep, $5.00. 

VOGEL (A.). A Practical Treatise on the Diseases of Children. Translated 
and edited by H. Raphael, M. D. Third American from the eighth German edi- 
tion, reyised and enlarged. Illustrated by six Lithographic Plates. 8vo. 
Cloth, $4.50 ; sheep, $5.50. 

YON ZEISSL (HERMANN). Outlines of the Pathology and Treatment of 
Syphilis and Allied Venereal Diseases. Second edition, revised by Maximil- 
ian von Zeissl. Authorized edition. Translated, with Notes, by H. Ra- 
phael, M. D. 8vo. Cloth, $4.00 ; sheep, $5.00. 

WAGNER (RUDOLF). Hand-Book of Chemical Technology. Translated and 
edited from the eighth German edition, with extensive Additions, by William 
Crookes. With 336 Illustrations. 8vo. Cloth, $5.00. 

WALTON (GEORGE E.). Mineral Springs of the United States and Canadas. 
Containing the latest Analyses, with full Description of Localities, Routes, 
etc. Second edition, revised and enlarged. 12mo. Cloth, $2.00. 

WEBBER (S. G.). A Treatise on Nervous Diseases: Their Symptoms and 
Treatment. A Text-Book for Students and Practitioners. 8vo. Cloth, $3.00. 

WEEKS (CLARA S.). A Text-Book of Nursing. For the Use of Traiuing- 
Schools, Families, and Private Students. 12mo. With 13 Illustrations, 
Questions for Review and Examination, and Vocabulary of Medical Terms. 
12mo. Cloth, $1.75. 

WELLS (T. SPENCER). Diseases of the Ovaries. 8vo. Cloth, $4.50. 

WYE I'll (JOHN A.).- A Text-Book on Surgery : General, Operative, and Me- 
chanical. Profusely illustrated. (Sold by subscription only.) 8vo. Buck- 
ram, uncut edges, $7.00; sheep, ss.un; half morocco, $8.50. 

WVLIE (WILLIAM G.». Hospital-: Their History, Organization, and Con- 
struction. 8vo. Cloth. $2.50. 



^^™ 



LIBRARY OF CONGRESS 



la 



m 



^^m 



■■:■•■■ '■■'-.•■ 





K 






